LIBRARY NGRESS. 

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UNITED STATES OF AMERICA 




A TREATISE 



ON 



DIPHTHERIA. 




js 



BY 



A. JACOBI, M.D., 

CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE COLLEGE OF PHYSICIANS AND 

SURGEONS, NEW YORK J PHYSICIAN TO BELLEVUE, MOUNT SINAI, 

AND THE GERMAN HOSPITALS, ETC. 





NEW YORK: 
WILLIAM WOOD & CO., 27 GREAT JONES ST., 

1880. 



<t 




Copyrighted by 
WILLIAM WOOD & COMPANY 

1880. 



STEAM PRESS OF 

H. O. A. Industrial School, 
187 & 189 E. 76th St. 



PREFACE. 



My first paper on diphtheria, which appeared in the 
American Medical Times of August nth and 18th, i860, 
was based on several hundred cases. Since that remote 
period I have seen thousands, and published my experience 
several times. After some " Contributions " in the Journal 
of Obstetrics and Diseases of Women and Children, Feb., 
1875, I collected and condensed my views in the second 
volume of C. Gerhardt's Handbuch der Kinderkrankhei- 
ten, 1877. Thus the present little book may be considered 
as an augmented edition of that monograph, with this ex- 
ception, that it contains less literature and more therapeu- 
tics. 

While thus admitting the claims of the practitioner 
as paramount, I was ever of opinion that a careful phy- 
sician and therapeutist required the very latest and 
soundest results of exact scientific investigations as the 
foundation and safeguard of his practice. For the physi- 
cian's science is no longer mere formula, and his art no 
routine. As the important questions of the identity and 
non-identity of " croup " and diphtheria, and of the parasitic 
or chemical nature of the diphtheritic poison are not yet 



iv PREFACE. 

settled to the satisfaction of all, their discussion is still in 
order. I am bound to say, however, that anxious though 
I be for a possible future success of a parasitic theory of 
nosogenesis, I have not been able to change my attitude 
in regard to the prevalent bacteria doctrine of diphtheria. 
I cannot look upon the bacteria epidemic in the medical 
journals, particularly of Germany, with the hasty conclu- 
sions and gratuitous assumptions of scores of experi- 
menters and writers, as anything but a calamity which, I 
trust, is but temporary. The safest verdict of the sober 
critic is still : " not proven." Fortunately, the non-accept- 
ance of the bacteria doctrine does not at all interfere with 
the success of the rational practitioner. 

The cases of diphtheria in every physician's practice are 
so numerous that, with very few exceptions, I shall abstain 
from detailing histories. What I hope to present in #iis 
little book is a condensed but tolerably extensive report 
on the present state of what is known about diphtheria, 
with my personal views on its pathology and treatment. 

A. JACOBI, M.D. 

New York, October 15th, 1880. 



When the above was written and printed, I came into 
possession of Supplement No. 7 of the National Board of 
Health Bulletin. It contains a " research on the effects of 
inoculating the lower animals with diphtheritic exuda- 



PREFACE. V 

tlon," by Drs. H. C. Wood and Henry F. Formad, with 
the signature, " University of Pennsylvania, July ist, 
1880." In thirty-two experiments, in which inoculation 
of diphtheritic matter was performed subcutaneously and 
in the mucous membrane of the mouth, the animals died 
in only six. The question naturally arises as to whether 
the few animals in which the inoculation was followed by 
death died of diphtheria or some other disease. Only in 
one case were there any exudations present in any organ 
which could give rise to the slightest suspicion that the 
animal died from diphtheria. It has been asserted by 
Oertel that animals which have been inoculated with diph- 
theritic material die with their internal organs infested 
with micrococci, and that the presence of these is charac- 
teristic of diphtheria. Wood and Formad have carefully 
examined the internal organs of the rabbits which died, as 
well as the blood of those which survived, and found no 
micrococci. In this their results are in complete accord 
with the very careful labors of Curtis and Satterthwaite. 

The utmost care is necessary to prevent the entrance 
into the blood of bacteria from without. Thus they have 
cut the jugular veins of a rabbit and examining the blood 
at once, found it entirely free from bacteria. When, how- 
ever, after the lapse of a few minutes the post-mortem was 
concluded and the heart opened, the blood therein con- 
tained possessed an abundance of these low organisms. 

If the animals did not die of diphtheria, of what did they 
die ? In every case the internal organs were tubercular. 



vi PREFACE. 

But this condition was not due to inoculation with diph- 
theritic material only. Nine experiments were made with 
small masses of innocuous foreign material which was put 
under the skin. In five out of nine of these experiments 
tubercle was found after death ; this large proportion ap- 
parently demonstrates that a simple local inflammation 
may in the rabbit act as a source of tubercular infection. 
Where diphtheritic matter was inoculated, inflammation 
was almost always induced at the seat of the lesion, with 
the formation of large lumps containing cheesy matter. 
These facts being so, it is a fair deduction that the tuber- 
cles were secondary to these inflammatory foci, and were 
therefore an indirect and not a direct result of the inocu- 
lation. Thus, diphtheritic membrane placed under the 
skin or in the muscles of rabbits may cause death in a few 
hours by the production of a blood poisoning which is 
not accompanied by any specific symptoms or lesions ; or, 
after many days, by the development of a secondary 
tuberculosis. 

Experiments prove that a pseudo-membranous tracheitis 
can be produced by placing the exudation matter in the 
trachea. Other experiments show that ammonia is able 
to produce in the cat and dog, as well as in the rabbit, a 
pseudo-membranous tracheitis. Prof. Oertel states that 
the membrane produced by cauterization of the trachea 
differs from diphtheritic membrane in containing no bac- 
teria. What has led him to such an assertion cannot be 
comprehended. When the death occurred very quickly 



PREFACE. Vll 

bacteria and micrococci may have been less abundant in 
the traumatic membrane than in that taken from the 
throat of patients, but when the animal survived some 
days, and the bacteria had sufficient time to develop them- 
selves, when, in other words, they were afforded as good 
opportunity of growth as in the natural disease, they 
were immensely abundant, in some cases seeming to make 
up a large part of the bulk of the membrane. 

If it be possible to produce a fatal pseudo-membranous 
tracheitis by placing the diphtheritic membrane in the 
trachea, and not possible to cause septicaemia by inoculat- 
ing other portions of the body with the same material, it 
would appear as though diphtheria might be originally a 
local disease with a subsequent septic poisoning. Experi- 
ments were therefore performed to determine whether any 
products of disease other than diphtheritic exudations are 
capable of causing pseudo-membranous tracheitis. In two 
of the ten experiments it was caused by the introduction 
of organic matter into the trachea. In both of the cases 
in which false membrane was produced, the injected 
material was pus ; only four such experiments were made, 
so that the proportion of successful results is very large ; 
much larger indeed than with true diphtheritic exudation 
in the experiments of Drs. Wood and Formad. 

Trendelenburg found that not only ammonia, but also 
various other chemical irritants are capable of causing the 
formation of false membrane in the trachea ; many years 
ago it was proven that tincture of cantharides will do the 



Vlll PREFACE. 

same thing. It would seem, therefore, that in the trachea 
the formation of a pseudo-membrane is not the result of 
any peculiar or specific process, but simply of an intense 
inflammation, which may be produced by any irritant of 
sufficient power. This fact, certainly, is very suggestive 
in regard to the pathology of diphtheria. 

A general view of the anatomical and clinical facts seems 
to indicate that the contagious material of diphtheria is 
really of the nature of a septic poison which is also locally 
very irritant to the mucous membrane ; so that when 
brought in contact with the mucous membrane of the 
mouth and nose it produces an intense inflammation with- 
out absorption by a local action. Whilst absorption is not 
necessary for the production of the angina, it is very 
possible that the poison may act locally after absorption 
by being carried in the blood to the mucous membrane. 
Further, under this theory it is possible that the poison of 
diphtheria may cause an angina which will remain a 
purely local disorder, no absorption occurring, or a simply 
local tracheitis produced by exposure to cold or some 
other non-specific cause may produce the septic material 
when absorption will cause blood poisoning, the case end- 
ing as one of adynamic diphtheria. Some such an ex- 
planation as these here offered seems to reconcile the 
antagonistic opinions concerning the value of local treat- 
ment in diphtheria ; because it is plain that the value of 
such treatment must largely depend upon whether the 
angina has or has not been preceded by absorption. 



PREFACE. IX 

From the exanthemata diphtheria differs from the fact 
that one attack in no way protects against a second. It 
ranks rather with septic diseases which may recur indefi- 
nitely. 

At present it seems altogether improbable that bacteria 
have any direct function in diphtheria, i. e., that they enter 
the system as bacteria and develop as such in the system, 
and cause the symptoms. It is, however, possible that 
they may act upon the exudations of the trachea as the 
yeast plant acts upon sugar, and cause the production of 
a septic poison which differs from that of ordinary putre- 
faction, and bears such relations to the system as to, when 
absorbed, cause the systemic symptoms of diphtheria. 
Now, these bacteria may be always in the air, but not in 
sufficient quantities to cause tracheitis, but enough when 
lodged in the membrane to set up the peculiar fermenta- 
tion ; whilst during an epidemic they may be sufficiently 
numerous to incite an inflammation in a previously healthy 
throat. 

The above extracts are reprinted almost literally from 
the remarkable paper of Drs. Wood and Formad, which 
is as conclusive as it is brief. Nothing equally excellent 
has been contributed to the literature of diphtheria for a 
long time. It appears to me that the mooted question of 
the essentiality of bacteria in regard to the nature and 
definition of diphtheria, to which many a page of this 
book had to be given up, is finally settled by them. While 
I regret the impossibility of quoting them at the proper 



X PREFACE. 

place and at proper length, I must not refrain from giving 
the greatest possible publicity to their conclusions, and 
expressing my satisfaction at being capable of sustaining 
my own position by their experiments, the skilful perform- 
ance of which is surpassed only by their happy results. 

A. JACOBI. 



CONTENTS. 



Chapter I. History i 

Chapter II. Etiology 27 

Chapter III. The Manner of Infection 51 

Chapter IV. Contagion and Incubation 57 

Chapter V. Symptoms 6S 

Chapter VI. Anatomical Appearances 108 

Chapter VII. Diagnosis 134 

Chapter VIII. Prognosis 149 

Chapter IX. Treatment 154 



A TREATISE ON DIPHTHERIA. 



CHAPTER I. 

HISTORY. 

Diphtheria is a specific, infectious, and contagious dis- 
ease characterized principally by epithelial changes in, 
and the exudation of fibrin on and into mucous membranes, 
the surface of wounds, and the rete Malpighii, thereby 
constituting the so-called pseudo-membrane. Under the 
names: ulcus syriacum, ulcus asgyptiacum, garotillo, mor- 
bus suffocans, morbus suffocatorius, affectus suffocatorius, 
pestilentis gutturis affectio, pedancho maligna, angina 
maligna, angina passio, mal de gorge gangreneux, ulcere 
gangreneux, angina polyposa, angine couenneuse, syn- 
anche, croup, diphtheritis, and diphtheria, the disease has 
been known and described at different periods by the 
writers of different nations. Aretseus, of Cappadocia, is 
notably the first of whom we have authentic proofs, if we 
except Asclepiades only, who is said to have performed 
laryngotomy. The description of the pharyngeal and 
laryngeal manifestations furnished us by the former, how- 
ever, can leave no doubt in our minds that he knew diph- 
theria and recognized it. Galen tells us that the pseudo- 
membrane was gotten rid of by coughing when the respi- 
ratory passages were affected by the disease, and by hawk- 
ing when the disease was in the pharynx. Cselius Aurelianus 
recognized diphtheria of the pharynx and larynx, as well 
i 



2 A TREATISE ON DIPHTHERIA. 

as the diphtheritic paralysis of the soft palate ; it is to him 
we are indebted for the information that Asclepiades 
resorted to scarification of the tonsils, and even to 
laryngotomy. Aetius, in the fifth century, advised against 
energetic local treatment and the forcible removal of the 
deposits before they were in a condition to fall off spont- 
aneously. 

In the literature of the middle ages, there are no proofs 
of the occurrence of diphtheria ; still, some reports of gan- 
grenous diseases, probably, have reference to it. Petrus 
Fosterus has given a fair description of an epidemic in 
Holland in the year 1557. Antonio Soglia, quoted by 
Chomel, describes an epidemic in Naples and Sicily (1563) 
which spread, in the following year, as far as Constantin- 
ople ; Joannes Wierus, epidemics in Dantzic, Cologne, and 
Augsburg (1565); Ballonius (Baillou), in Paris (1576). In 
Spain, epidemics raged in the years 1583, 1587, 1 59i r 1596, 
1 600- 1 605, and 161 3. Mercado (1608) tells of a child that 
had communicated the disease to its father by biting his 
finger. Cascalez advised gargles of solutions of alum and 
of sulphate of copper. Herrera (1 5 1 5) described diphtheria 
of the skin and of wounds, and looked upon the pseudo-mem- 
brane he found after death as the essential characteristic 
of the disease. Heredia, in 1690, recognized the suffocative 
and asthenic forms, as well as the paralysis of the soft 
palate, of the pharynx, and of the limbs ; he also called at- 
tention to the occurrence of relapses, which he attributed 
to the absorption of the morbid products, and endeavored 
to prevent by cauterization. In Portugal, too, there have 
been epidemics in early times. Barbosa, with whose work 
the world has become acquainted mainly through the 
meritorious labors of J. B. Ullersperger, describes one 
which occurred in 1626. Among the older writers on the 
subject we may mention Juan de Villareal, 161 1, and' 
Francesco de Figueiras in Lima, 1616. In Italy the first 
epidemic raged in 1618; Rene, Moreau, and Bartholinus 
detail a large number of literary proofs in support thereof ; 



ITS HISTORY. 3 

it was characterized by its marked contagiousness and its 
depression of the vital powers, together with the weak- 
ness of the mental faculties left after an attack of the dis- 
ease. The only autopsy, made in 1642, from a report by 
M. A. Severino, revealed the presence of pseudo-mem- 
brane in the larynx.* In Germany the disease was de- 
scribed by Wedel, in 1718. The epidemics observed by him 
were not very instructive, yet they sufficed to teach the 
importance of isolating the sick. 

In the New England States diphtheria has appeared in 
the seventeenth century. Samuel Danforth, graduate of 
Harvard University, in 1643, had twelve children. The 
first died at the age of six months. The " next three being 
attacked by the ' malady of bladders in the windpipe,' in 
December, 1659, it pleased God to take them all away at 
once, even in one fortnight's time." This happened at 
Roxbury, Mass. (Biographical sketches of graduates of 
Harvard University, etc. By John Langdon Sibley, vol. 
I., Cambridge, 1873, p. 91. f) 

John Josselyn, Gent., in " an account of two voyages to 
New England, made during the years 1638, 1663 " (Boston, 
Wm. Veazie, 1865)4 writes as follows (p. 141): "also 
they " (the English in New England) " are troubled with 
a disease in the mouth or throat, which hath proved mor- 
tal to some in a very short time, quinsies and impostuma- 
tjons of the almonds, with great distempers of cold." As 
Josselyn on his second voyage spent eight years in New 
England (principally in Maine), the foregoing must point 
to an epoch not later than 1671, and the manner in which 
he expresses himself shows that he does not speak of a re- 
cent invasion, but of a disease which had been common for 

* See literature in Sanne, Diphth., 1877, and Hirsch, Hist. Ge,ogr. Path., II. 

f This important historial reference I owe to the watchfulness of Dr. 
Elsworth Eliot, New York. 

X This book was published in 1674, and reprinted in 1833, by the Massa- 
chusetts Historical Society, and may be found in the third volume of the third 
series of their collections. 



4 A TREATISE ON DIPHTHERIA. 

some time. I have no proofs of epidemics during the fol- 
lowing decades, but the year 1735 marks the recurrence of 
epidemics. In a " Compendious History of New Eng 
land " by Dr. Jedediah Morse, D.D., and Rev. Elijah 
Parish, Charlestown, 1804, we read with reference to the 
epidemic of 1735, that the throat became swollen and 
coated with white and ash-gray spots, an eruption ap- 
peared on the skin; great debility overcame the entire 
body, with a marked tendency to putridity. The disease 
first appeared in 1735, at Kingston, N. H. Wm. Douglass 
(The Practical History of anew epidemical Eruptive Mili- 
ary Fever with an angina ulcusculosa, which prevailed in 
Boston, New England, in the }'ears 1735 and 1736) says of 
this epidemic : " It was first noticed in Kingston township, 
on the 20th of March, 1735, about fifty miles eastward of 
Boston. As this was an inland place of no considerable 
trade or importance, it was thought (incorrectly perhaps) 
to be of indigenous origin, and not' of foreign importation. 
The first victim was a child who died in three days ; and 
about a week after, three children were seized in another 
family four miles distant ; and they also died on the third 
day. It continued spreading gradually, seizing here and 
there particular families, with that degree of violence 
that of the first forty cases none recovered. Some of the 
patients died of a sudden acute necrosis, or mortification ; 
but most of them were carried off by a sympathetic 
affection of the fauces, neck, or air-passages ; or, by an in- 
filtration and tumefaction of the chops, and forepart of the 
neck which became so enlarged and turgid, as to bring 
upon a level all parts lying between the chin and sternum, 
occasioning a strangulation of the patient in a very short 
time. After a few weeks it spread from Kingston to the 
neighboring townships, but in a milder form. No reasons 
could be given for this greater malignity in Kingston, 
except, perhaps, the prevalence of damp places near large 
ponds, and fresh water, but sluggish streams, like in those 
localities which produce the rot in sheep. There may 



ITS HISTORY. 5 

also have been bad medical treatment. Its first recognized 
appearance in Boston was on the 20th of August, 1735, in 
a child . . . who had white specks in the throat, and a 
cutaneous efflorescence. A few more . . . were seized in 
like manner. Towards the end of September it appeared 
in several parts of the town of Boston, with more decided 
complaint of soreness of the throat. The tonsils were 
swelled and specked ; the uvula was relaxed ; there was 
slight fever, and an erysipelas or scarlet fever like efflo- 
rescence on the neck, chest, and extremities. The first 
alarming case was in the beginning of October, in a young 
man. He had lately arrived from Exeter, to the eastward 
of Boston, where his brother had died of the same illness. 
His symptoms were great prostration of strength, a single 
speck on one of his tonsils, and colliquative sweats. . . . 
It increased during the winter up to the second week in 
March, 1736; when it was at its height, there being 
twenty-four burials in all, during the week (instead of nine 
or ten). . . . The disease was so much milder in Boston 
than in some of the townships where it first prevailed that 
many could not be persuaded that it was the same disorder. 
. . . To the eastward of Boston, at times, one in three 
died, in other places one in four, and in scarce any towns, 
less than one in six; whereas in Boston not above one in 
thirty-five succumbed." 

The disease cannot have remained so mild for any 
length of time in Boston, for on August 5th, 1740, the pre- 
face to the letter of I. Dickinson, A.M., dated at Cam- 
bridge, speaks of the " most malignant disease which had 
raged for a long time in the place where he lives, and which 
had commenced its fatal progress in these parts," and of the 
" fresh alarm by a return of that astonishing distemper 
among us." The letter was written in 1738, and published 
two years afterward, under the title of : " Observations on 
that terrible disease, vulgarly called the Throat Distemper, 
with advices as to the method of cure, in a letter to a friend. 
By I. Dickinson, A.M. Boston. Printed and sold by S. 



6 A TREATISE ON DIPHTHERIA. 

Kneeland and T. Green, in Queen Street, over against the 
Prison. 1740."* 

The clergyman to whose observations and industry we 
owe this short letter appears to have seen most of the 
forms of diphtheria. He describes cases which 

1. " Begin with a shivering, a chill, or with stretching, or 
yawning, which is quickly succeeded with a sore throat, 
a tumefaction of the tonsils, uvula and epiglottis, and 
sometimes of the jaws, and even of the whole throat and 
neck. From the second to the fourth day there may be a 
miliary eruption, in some exactly resembling the measles, 
in others more like the scarlet fever, in others like the 
confluent small-pox." This form proved fatal but seldom. 

2. " It frequently begins with a slight indisposition, much 
resembling an ordinary cold, with a listless habit, a slow 
and scarce discernible fever, some soreness of the throat 
and tumefaction of the tonsils ; and perhaps a running of 
the nose, the countenance pale, and the eyes dull and 
heavy. Sometimes vehement sickness of the stomach, a 
perpetual vomiting ; and sometimes by ejecting of black 
or rusty and fetid matter, having scales like bran mixed with 
it, which is a certain index of a fatal mortification. . . . 
When the lungs are thus affected, the patient is first 
afflicted with a dry, hollow cough, which is quickly -suc- 
ceeded with an extraordinary hoarseness and total loss of 
the voice, with the most distressing asthmatic symptoms 
and difficulty of breathing, under which the poor miser- 
able creature struggles, until released by a perfect suffo- 
cation, or stoppage of the breath. . . . Comparatively few 
recovered. . . . Some expectorated incredible quantities of 
a tough whitish slough from their lungs. ... I have seen 
large pieces of this crust, several inches long and near an 
inch broad, torn from the lungs by the vehemence of the 
cough." 

* Reprinted by Stephen Wickes, A.M., M.D., on p. 87 to 99 of his excellent 
" History of Medicine in New Jersey, and of its Medical Men, from the 
settlement of the Province to a.d. 1800. Newark, N. J., 1879." 



ITS HISTORY. 7 

3. It sometimes appears in the form of an erysipelas, 
in some with all the terrible symptoms above described, 
in some with none of them. 

4. In external ulcers all over the body. 

5. In glandular swelling's with favorable result only 
when they undergo suppuration, and lastly as sudden or- 
thopncea, which proves fatal in from one to three days. It 
shows its peculiar character by the presence of the " crus- 
tula in the throat, which determines it to be a sprout from 
the same root with the symptoms described above." 

The treatment of the Reverend is a singularly rational 
one ; moderate temperature, disinfectant applications, warm 
poultices to swollen glands, but moderate purgation, and 
mild stimulants, all of them in the compound mixtures of 
his time, form his armamentarium. He adds that there is 
no security against a second attack ; he has seen it four 
times in a patient in one year, the last proving fatal, and 
known numbers that have passed through it in the erup- 
tive form in the summer season, " that have died with it 
the succeeding fall or winter, though I have never seen 
any upon whom the eruptions could be brought out more 
than once." 

According to Dr. CadwaladerColden, in a letter written 
1753 to Dr. Fothergill (printed in vol. 1st of the London 
Med. Observations and Inquiries, pp. 21 1-225), the " throat 
distemper " spread from Kingston gradually westward, so 
that it did not reach the Hudson river till near two years 
afterwards. It continued some time on the east side of the 
river, before it passed to the west, and appeared first in 
those places to which the people of New England chiefly 
resorted for trade, and in places through which they trav- 
elled. It continued to move westerly, till it probably 
spread over all the British Colonies on the continent. Dr. 
Colden's description resembles that of Dr. Douglas. A 
few of the points emphasized by him are the following. 
Though the disease was evidently propagated by infection, 
yet children and young people were only subject to it, with 



8 A TREATISE ON DIPHTHERIA. 

the exception of a few. A very few aged people who were 
taken died. It did not spread equally to all places that 
were proportionately exposed to the infection. The 
poorer sort of people were more liable to it, and they who 
lived on low and wet grounds and on poor scorbutic diet. 
In some places, only a few persons or families were seized; 
while in others, all escaped. In some families it passed like 
a plague through all their children ; in others, only one or 
two were seized. Some were attacked at great distances. 
Some had it mildly, while others in the same place and at 
the same time had it most violently. . . . "Many have not 
been confined to their beds, but have walked about the 
room, till within an hour or two of their death. And the 
complaint has often appeared no way dangerous, at first, 
to the attendants, till the sick were almost in the last 
agonies, though the patients themselves are generally de- 
jected and apprehensive. . . . When the surfaces of the 
tonsils, after the sloughs were cast off, appeared of a very 
fiery-red color, there was some, or even great danger ; 
but when they were covered with a black crust it was 
often a fatal omen, as also where hemorrhages followed 
any slight scratch. . . . When the disease first appeared, 
it was treated in the usual way for a common angina, and 
no plague was more destructive. . . . The orifices made 
by the lancet in bleeding, and the adjacent parts were apt 
to become diseased. So likewise the places where blisters 
were applied. The ichor which issued from them cor- 
roded the parts upon which it flowed, and even slight 
scratches became as it were mortified. ... A girl about 
ten years of age, while the throat distemper was prevail- 
ing, had sores on her private parts like those on the tonsils 
of others, but no symptom of the disorder appeared in her 
throat." 

The epidemic does not appear to have abated much after 
this time. For, in his first letter to Mr. Hugh Gaine, 
of New York, dated Jamaica (Long Island), Oct. 28th, 
1769 (reprinted in the " Medical Repository," Vol. V., 



ITS HISTORY. 9 

New York, 1802, p. 97), Dr. Jacob Ogden refers to the 
" distressed condition of the people in Boston and Oxford, 
occasioned by the fatal effects of the malignant sore-throat 
distemper." He also refers to the prevalence of the dis- 
ease in his neighborhood. The symptomatology contained 
in his second letter, dated Jamaica, Sept. 14th, 1774, con- 
tains, briefly, a recapitulation of the excellent description, 
mainly of the milder forms, as given by Douglas, while 
the first is given up to treatment alone. Calomel and a 
compound mixture containing Seneka (Polygala s.) are 
highly recommended. Seneka was, credit not being given, 
claimed as the sufficient remedy in diphtheria " without 
any other medicine — the use of mercury may, however, 
sometimes, as in the symptomatic kind, be necessary " — by 
John Archer, Jr., in " an inaugural dissertation on cynanche 
trachealis, commonly called croup or hives," Philadelphia, 
1798, p. 46, and " on the use of the Radix Seneka in the cure 
of croup. Letter to B. S. Barton, M.D." Med. Repos., I., 
p. 120, 1798 ; and II., 1799, p. 27. In connection with the 
above, a few sentences will be of interest as showing the 
tendency to disinfecting treatment on the part of the old 
practitioner. " Detergent gargarisms, or injections, are 
of service when the patient is of an age capable of using 
them. The air of the room where the sick lie might also 
with advantage be continually impregnated with the 
steam of vinegar. Sea-coal might be burnt in the winter 
instead of other fuel; and, in the summer, the room might 
be fumigated with myrrh, rosin, and sulphur, strewed on 
burning coal often in a day. These fumes, if diligently 
persisted in, would, it is more than probable, not only 
much benefit the sick, but be the best means of preventing 
the infection from spreading in the family " (Med. Repos., 
V., 1802, p. 103). 

If we disregard the dubious reports of Le Cat concern- 
ing epidemics in Rouen in 1736 and 1737, we must con- 
sider them to have first occurred in France in 1745, 
having begun in Paris (Astruc, Malouin, Bouillaud, Cho- 



10 A TREATISE ON DIPHTHERIA. 

mel, du Hamel, Boucher, Navier), and later invaded the 
provinces (Rolin, Grandvilliers). Chomel has given us an 
accurate description of paralysis of the soft palate, and 
reports a case of diphtheritic strabismus. The English 
epidemic, described by Starr, occurred in the years 1744 
to 1748; that by Huxham, in Plymouth, in 175 1 to 1753. 
The first Swiss epidemic happened in 1752, the Dutch in 
1747 (Zaff), the Swedish in 1755 (Berg). 

During the subsequent part of the eighteenth century, 
but two writers are worthy of especial notice, Home, a 
Scotchman, 1765 ; and Samuel Bard, an American, 1771. 

Home deserves credit for having distinctly drawn the 
line between the pseudo-membranous and the gangrenous 
affections, and also for having endeavored, to his utmost, 
to convince his colleagues that croup and angina maligna 
were two distinct diseases/ notwithstanding all that had 
been uttered since the time of Aretasus to prove their 
identity. No matter in what way he tried to explain the 
false membranes — he looked upon it as an aggregation 
of mucus — he found it, and gave an accurate description 
thereof. He sought for it exclusively in the respiratory 
tract, and disregarded any connection between it and the 
false membrane found in the pharynx. 

Bard's experience was very extensive ; he saw membra- 
nous pharyngitis, membranous laryngitis, and membra- 
nous pharyngo-laryngitis ; he speaks of the membrane 
affecting the skin, of paralysis of the muscles of deglu- 
tition, and of the larynx, and likewise of paralysis of the 
lower extremities, as sequelae. He looked upon the mor- 
bific process as the same, whichever were the mucous 
membranes attacked, and made a distinction only accord- 
ing to the localization of the disease. The influence which 
he might have exercised in shaping the professional opinion 
on the nature of the disease did not make itself felt, partly 
because of the classical modesty of the New York physi- 
cian, and partly because of his remoteness from the cen- 
tres of European learning. 



ITS HISTORY. II 

" Bard's article is among" the calmest, wisest, and most 
accurate that has ever been written on diphtheria, both 
before and since his time."* While his style is classical in 
its simplicity, his observation is astonishingly correct, and 
his conclusions as to the actual identity of all the diph- 
theritic processes in the most various clinical symptoms 
unimpeachable this very day. His description of the vari- 
ous forms of pharyngeal diphtheria is painfully good, his 
observations on cutaneous diphtheria very accurate, his 
few dissections well recorded, particularly when he speaks 
of tracheal and tracheo-laryngeal diphtheria, and his his- 
torical reviews very judicious indeed. " Upon the whole, 
I am led to conclude that the morbus strangulatorius of 
the Italians, the croup of Dr. Home, the malignant ulcer- 
ous sore-throat of Huxham and Fothergill, and the disease 
I have described, and that first described by Dr. Douglas, 
of Boston, however they may differ in symptoms, do all 
bear an essential affinity and relation to each other ; or 
are apt to run into each other, and, in fact, arise from the 
same leven. The disease I have described appeared evi- 
dently to be of an infectious nature, and being drawn in 
by the breath of a healthy child, irritated the glands of 
the throat and wind-pipe. The infection did not seem to 
depend so much on any prevailing disposition of the air, as 
upon effluvia received from the breath of infected persons. 
This will account why the disorder sometimes went 
through a whole family, and yet did not affect the next- 
door neighbors. Here we learn a useful lesson, viz. : to 
remove young children as soon as any one of them is taken 
with the disease, by which many lives have been saved 
and may again be preserved." 

" A letter from Peter Middleton, M.D., to Mr. Richard 
Bay ley on the croup," dated New York, Nov. 30th, 1780, 
which had become absolutely rare for some time, and was 
reprinted, therefore, in the Med. Repos., Third Hexade, 

* John C. Peters in West Virginia Med. Stud., Aug., 1876. 



12 A TREATISE ON DIPHTHERIA. 

Vol. II., N. Y., 1811, p. 347, contains Dr. Middleton's 
views on the nature of the prevailing illness. He was a 
Scotchman, who emigrated to the colony in 1752, and 
coincided with Home's views on croup. He insists upon 
having met with local membranous croup only, though 
he does not " presume to say that it never is complicated 
with the malignant sore-throat," and asserts to have been 
very successful with jugular venesections, blisters over the 
throat, and evacuants. 

Dr. Richard Bayley's letter to Dr. William Hunter, of 
London, written and published about the year 1781, shared 
the fate of Dr. Middleton's pamphlet. It got scarce, and 
at last lost, so that only a part of it could be reproduced in 
the Med. Repos. of 1809, Second Hexade, Vol. VI., p. 331, 
while the then lost part was supplied in that of 181 1, 
Third Hexade, Vol. II., p. 345. While Dr. Middleton denies 
having seen the throat distemper with his cases of croup, 
Dr. Bayley describes the same class of cases with the ex- 
act symptoms of pharyngeal diphtheria. The main symp- 
toms were, however, with him also those of local obstruc- 
tion and suffocation, of " angina trachealis." He considers 
it as *' an inflammatory disease, the treatment of which must 
vary in every degree according to its violence ; and though 
the common antiphlogistic treatment will in some cases 
relieve, if early applied, yet the most desperate may yield 
to repeated bleedings ad deliqiiium from the jugulars, the 
free use of tartar emetic and other evacuants, with a large 
blister covering the larynx and aspera arteria, while the 
mucus filling up the ramifications of the bronchia may be 
emptied by the action of vomiting." 

Jurine, in his prize essa} T of 1807, goes no further than to 
deny the gangrenous nature of angina maligna, and to 
emphasize the frequent complication of membranous croup 
with membranous pharyngitis. It was reserved for Bre- 
tonneau to enforce attention to the ideas of Bard, by 
asserting (though he did not mention either his monograph 
or its French translation of 1 811) the identity of angina 



ITS HISTORY. 13 

maligna, or by whatever other title it may be known, with 
membranous laryngitis, and, by inaugurating his theory 
with a new name for the disease, to perpetuate the views 
expressed therein. First and foremost, he called attention 
to the continuity of the membrane (according to him, com- 
posed of coagulated mucus and fibrin) of the nose, pha- 
rynx, and respiratory tract, its identity with certain morbid 
conditions of the skin, and promulgated the theory that 
diphtheria is a specific disease, an affection sui generis, to 
be distinctly separated from a catarrhal, as well as from a 
scarlatinous inflammation. 

The modern history* of diphtheria may be dated from 
June 26th, 1 82 1, when Bretonneau read his first essay on 
that subject before the French Academy of Medicine, and 
gave to the disease the name it now bears. His second 
and third (Nov. 25th) papers belong to the same year, his 
fourth being read in March, 1826, his fifth appearing in 
the Archives Gen. of January and September, 1855. It 
was only in 1826 that the material, previously gathered* 
was summed up in his celebrated monograph. Before 
this time, however, the separate essays had received promi- 
nence from the reports and commentaries of Guersant. who 
laid particular stress on the statement that diphtheria is a 
non-gangrenous affection, identical, and even synchronous 
with croup in the majority of epidemics. Since that epoch, 
the literature on the subject has assumed enormous pro- 
portions. A short resume of the writings in reference 
thereto that have since appeared is all that can reasonably 
be offered, but it is interesting to note that many impor- 
tant questions bearing on the etiology, pathology, and 
treatment of the disease were then, as they still remain, 
mooted points. 

Bourgeoise, in a paper read before the Academy, and 
Brunet, already in 1823, expressed their belief in the con- 
tagious character of the disease. Desruelles (1824) sees a 

* Compare John Chatto, in "Memoirs on Diphtheria," Sydenh. Soc. 



14 A TREATISE ON DIPHTHERIA. 

diagnostic point between the sporadic and the epidemic 
forms in the participation of the brain in the latter. Louis 
referred a number of cases of croup in adults to pharyng- 
eal diphtheria as their source. Gendron (1825) recom- 
mends lunar caustic and scarification of the tonsils as pro- 
phylactic and curative agents. Mackenzie considers that 
croup has its origin in the fauces, and urges the employ- 
ment of lunar caustic. Billard (1826) denies the specific 
character of diphtheritic inflammation. Hamilton de- 
scribes cases that terminated in suppuration, and which 
he therefore distinguishes from Bretonneau's cases. He 
describes two modes of termination of the disease, one in 
croup, the other in a state of debility arising from the 
effect of the absorbed secretion on the respiratory nerves. 
Pretty looks upon those cases of croup that have their 
original seat in the tonsils, as contagious. Conolly gives 
us a description of the disease similar to that of Bretonneau, 
and recommends calomel. Bland (1827) explains the dif- 
ference between croup and diphtheria. Deslandes de- 
clares them to be identical. Bretonneau publishes a work 
in which he compares diphtheria with scarlatina anginosa, 
and recommends the use of alum. Emmangard is the first 
one of the " physiological " school who, likening diphtheria 
to typhoid, and claiming its origin in a malarial infection, 
calls it " angina gastro-enterica." Blanquin (1828), follow- 
ing him, recommends bleeding, by which he lost only 
fourteen cases out of three hundred. On the other hand, 
Belden recommends lunar caustic, Gendron lunar caustic, 
antiphlogistic treatment and scarification, and Lormel 
antiphlogistic treatment and counter-irritation. Aber- 
crombie is in favor of distinguishing diphtheria from croup, 
but reports a number of cases of diphtheria of the pharynx 
that terminated fatally by stenosis of the larynx. Ribes, 
who encountered the disease in nine members of a single 
family, asserts that croup rarely occurred without a pre- 
ceding diphtheria, in his experience ; he advises an ex- 
amination of the throats of apparently healthy individuals. 



ITS HISTORY. 15 

Fuchs relates the history of epidemics of angina maligna, 
and declares croup to be a genuine angina maligna tra- 
chealis, which only does not run through all the stages. 
Broussais opposes the identity of croup and diphtheria 
(1829), and gives a report of cures by means of antiphlogis- 
tic regimen andlaryngotomy. Diphtheria and gangrenous 
angina are synonymous with him. Gendron expresses a 
belief in the identity of diphtheria and gangrenous angina, 
and advises antiphlogistics and lunar caustic, opposing the 
use of muriatic acid. Roche considers the membrane 
rather of hemorrhagic than of inflammatory origin, and 
consisting of discolored fibrin. Menon employs sinapisms, 
cathartics and antimony, but no topical applications. 
About the same time, Trousseau is endeavoring to clearly 
establish the diagnostic points between diphtheria and 
scarlatinous angina. Shortly after (1830), he reports 
cases of diphtheria having their origin in artificial blister- 
ing-wounds, and of diphtheria of the skin giving rise to 
throat affections, and diphtheria of the throat followed by 
skin disease. Regnier declares antiphlogistic treatment 
useless. Archambault-Reverdy protests against the 
abuse of local treatment. Velpeau, as also Girouard, 
two years later, suggests alum and lunar caustic. In 
1 83 1, we find Broussais inclining to the " gastro-enteric " 
view, and opposing Bretonneau's theory of the nature 
of the disease; while Gendron has thrown down the 
gauntlet in favor of its being contagious. J, F. Hoff- 
man cites a severe case that ultimately recovered with 
consecutive paralysis of certain cranial nerves. Cheyne 

(1833) makes a stand against the " confounding of croup 
and cynanche maligna under the name of diphtheritis." 
Gendron reports two fatal cases after tracheotomy, 
and recommends lunar caustic. Lemercier favors the use 
of lunar caustic and bleeding. Cotlirieau complains of the 
too infrequent employment of internal remedies. Richard 

(1834) advocates antiphlogistics and cauterization. Bour- 
geois witnessed an epidemic succeeding mumps, and found 



l6 A TREATISE ON DIPHTHERIA. 

muriatic acid, locally applied, of great service. Fricout 
and Burley (1836) declare their belief in the contagious- 
ness of the disease. Bouillaud attacks the theory of 
its specific character on the ground that abstraction of 
blood produced favorable results. Stokes makes a distinc- 
tion between primary and secondary croup, according to 
the original seat of the affection (1837). Baumgartner 
(1838), as also Bouchut, many years after, recommends 
partial removal of the tonsils, and Ruppius, bleeding and 
calomel; Bretonneau (1839), caustics; Geddings, of 
Charleston, S. C, lunar caustic and muriatic acid ; Ben- 
son (1840), calomel internally, lunar caustic and mineral 
acids locally ; Duplan (1841), bleeding and emetics. Dur- 
ing the same year, Kessler advocates the view of its con- 
tagious nature, and Rilliet .and Barthez adduce evidence 
of the occurrence of ulceration and gangrene in the course 
of the disease. Taupin, like Ribes, enjoins a methodical 
examination of the throat of every patient, during the pre- 
valence of an epidemic of diphtheria, whatsoever be the 
disease from which the child suffers. Boudet (1842) op- 
poses Bretonneau's hypothesis that croup is a descending 
diphtheria, and holds to the identity of diphtheria and 
gangrenous angina. In this contest, Durand (1843) a l s0 
takes sides against Bretonneau, and lays particular stress 
on the point that the diphtheritic patient succumbs rather 
from the severity of the constitutional symptoms than 
from suffocation. Rilliet and Barthez, on the other hand, 
rally to the support of the attacked master, asserting that 
the usual form of croup, and that resulting from a declin- 
ing diphtheritis, are one and the same, while they claim 
that diphtheritis and gangrenous angina are distinct affec- 
tions. Becquerel advises local cauterization and tonic 
treatment; Moland (1845), lunar caustic; Daviot (1846), 
lunar caustic, and in children over ten years, depletion ; 
Hein (1849), calomel and lunar caustic; Beck (1850), 
emetics, while he opposes caustics ; Bourgeois, calomel 
and lunar caustic ; Brown, mercury and lunar caustic ; 



ITS HISTORY. 1/ 

Welsch, a strong solution of nitrate of silver, which he 
prefers to alum, sulphate of copper, and muriatic acid. 

Meanwhile the strife regarding the nature of the disease 
continued. Guersant and Blache (1844) describe the 
" stomatite couenneuse " (noma, stomacace, according to 
them, the rarest kind of gangrenous angina) as a form of 
Bretonneau's diphtheritis, and Landsberg raises the ques- 
tion whether a nerve inflammation, present in a certain 
case, was to be looked upon as an accidental or an essen- 
tial feature of the disease, and finally comes to the con- 
clusion, with Schonlein, that it was a neurophlogosis 
dependent on the disease. Bouisson (1847) reports a case 
of diphtheritic conjunctivitis resulting in loss of the eye. 
Robert publishes his observations on diphtheria of the 
skin and of wounds, which he attributes to an atmospheric 
contamination in crowded wards of hospitals, and looks 
upon it, with Delpech and Eisenmann, as a form of hospi- 
tal gangrene. Virchow, in the same year, distinguished 
the catarrhal, croupous, and diphtheritic varieties of the 
disease. The ensuing years are especially rich in sugges- 
tions as to the mode of treating diphtheria. In France, 
the alkaline treatment leads the van; Baron (185 1) em- 
ploying Vichy water; Lemaire (1853), bicarbonate of soda. 
Daga (1854) urges the topical application of concentrated 
muriatic acid. Meanwhile reports of paralysis of the soft 
palate after diphtheria came from Morisseau, from Trous- 
seau and Lasegue, and lastly (1854— '59) from Maingault. 
The subject of diphtheritic conjunctivitis was studied by 
A. v. Graefe (1854), who encountered the disease as a com- 
plication of diphtheria of the pharynx, nose, and skin, and 
hence considered it a part of the general disease rather 
than an independent local affection. Diphtheria, in its 
effects on the system, had at the same time been investi- 
gated by Trousseau, who sums up with the statement that 
the principal source of danger lies in the invasion of the 
larynx, and that the large majority of cases of croup be- 
gan as a diphtheria of the pharynx, but that, even without 
2 



1 8 A TREATISE ON DIPHTHERIA. 

the occurrence of a laryngeal localization, many cases ter- 
minate fatally owing to adynamia. 

Outside of France, too, the subject had attracted atten- 
tion. West, who had never seen the disease occur pri- 
marily, describes diphtheria appearing as a complication 
of measles. Wunderlich and Bamberger (1855) enrich the 
records with their wonted zeal. The latter divides the 
inflammations of the mouth and pharynx into the catar- 
rhal and croupous forms, and considers croup and 
diphtheria subdivisions of the latter form, differing only in 
degree. Meanwhile the French were almost exclusively 
engaged on the treatment. Bretonneau, while expressing a 
few remarks on the contagiousness of diphtheria, urges 
the employment of lunar caustic both as a remedial and as a 
prophylactic agent ; similarly Latour and Ferrand. Mar- 
chal de Calvi thinks that the duration of the disease is 
thereby lengthened, and dwells on the favorable effects of 
the alkaline treatment, against which Latour and Marcuel 
express themselves. Valentine calls to his aid the actual 
cautery; A. Smith and Isambert (1856), Roux and Wood- 
ward (1857) having recourse to the chlorate of potassium, 
which, in the hands of the last-mentioned, would seem, 
however, to have been only serviceable in mild cases. Ap- 
plications of tincture of iodine are recommended by 
Lecointe, Perron, and Boinet, and of bromine and bromide 
of potassium by Zanam (1856). Popo expresses himself 
in favor of muriatic acid and opposed to the use of alkalies ; 
Gigot, in favor of alkalies and against cauterization (1857)- 
The paralysis of the muscles of deglutition is discussed by 
Dehaenne, who had contracted the disease, and the pa- 
ralysis of other muscles by Faure. A case of diphtheria of 
the tonsils, nipples, and vagina, in a woman recently con- 
fined, followed by infection of the new-born, and the death 
of both, is reported by Mahieux ; and cases of diphtheritic 
conjunctivitis by Grichard, Warlomont, and Testelin. The 
same year, Isambert published a work in which he divided 
the diphtheritic affections into three forms, viz. : angine 



ITS HISTORY. 19 

couenneuse, scarlatinous angina, and diphtheritic angina. 
The last-mentioned is further subdivided into a croupous- 
diphtheritic angina, in which croup of the larynx plays an 
important part, and into that form in which death results 
from adynamia; in the latter form there is a marked 
swelling of the lymphatic glands. Apparently, at this time, 
the epidemic in Paris underwent a considerable change, 
for the croupous form does not occur by far as frequently 
as Bretonneau had asserted, and croup of the larynx with- 
out a preceding diphtheria of the pharynx was observed 
more often than he would lead us to believe. 

Thenceforward the literature on this subject became 
unlimited, and the year 1858 saw an epidemic of contribu- 
tions thereto. Beale calls his microscope into requisition, 
and finds no parasites. Laycock endeavors to trace the 
disease to the presence of the oidium albicans. Welks 
finds the same parasite in other affections. Cammack 
declares the diphtheritic membrane to be herpetic. Fe- 
ron calls Bretonneau's mild form of the disease an herpe- 
tic angina, accompanied by a formation of false membrane ; 
Gabler looks upon the same form as herpetic in charac- 
ter, and frequently accompanied by herpesHabialis. Bou- 
chut declaims against the identity of diphtheria, croup, 
and gangrene. Condie describes the disease as occurring 
with scarlatina. Litchfield claims that it is a concealed 
scarlatina, and Hillier (1859) that it has some connection 
with scarlatina. Millard cites one case in the course of 
which gangrene occurred, and another in which skin, 
mouth, pharynx, respiratory passages, oesophagus, and 
vulva were affected at the same time. Harley vainly 
endeavored to inoculate the disease in animals. Stephens 
declares the disease to be infectious. Sanderson looks 
upon it as identical with the angina maligna of the aged- 
Farr considered the exhalations from sewers an important 
etiological factor. Sellerier, Kingsford, and Harley (1859) 
report paralyses as sequelae. Mangin speaks of a specific 
eruption ; Ward, of an accompanying purpura. Bouchut 



20 A TREATISE ON DIPHTHERIA. 

and Empis remarked the frequent presence and corre- 
sponding danger of albuminuria ; so did Wade. Maugin 
calls attention to the fact that, when present in diphtheria, 
it occurs early, whereas in scarlatina it is seen during the 
period of desquamation, and is not of frequent occurrence 
even then. Gull gives an account of cases in which death 
resulted from asthenia, and speaks of a nerve lesion which 
he attributes to the severity of the local inflammation. 
Hildige describes diphtheritic conjunctivitis as seen in 
Grasfe's practice, and looks upon it as contagious. Magne 
denies its contagious or infectious character. Mackenzie, 
while probably having seen false membrane appear on the 
conjunctiva when in a state of inflammation, yet refuses 
to recognize diphtheritic conjunctivitis as a distinct dis- 
ease. Reports likewise come from North and South 
America. According to Boston Med. and Surg. Journ., 
Vol. LIX., 1858, the epidemic in Providence, R. I., had a 
similar course to that in England ; that in Albany and 
Troy, described by Dr. Willard (calomel treatment), being 
very malignant, and in New York, described by me, i860, 
moderately severe. Odriozola, in a report from Lima, 
testifies to the*immunity enjoyed by the blacks. 

Therapeutical contributions are not less numerous. 
Iron, generally in the form of the chloride, is recom- 
mended by Barry (who also employs chlorate of potass., 
counter-irritation, and cauterization with nitrate of silver), 
Fourgeaud, in San Francisco, Gigot and Jodin, Heslop 
(together with cauterization with muriatic acid) ; Hough- 
ton (the same, and in addition tonic diet) ; Kingsford 
(tonics, nutritive enemata, chlorate of potass.) ; and Stiles 
(together with the topical employment of concentrated 
saline solutions). Bryan advises the use of guaiac inter- 
nally and salt topically ; Cazin, lemon-juice ; Duche, sul- 
phur ; Gay, tracheotomy ; Lambden, chlorate of potassium 
with muriatic acid, and cauterization with nitrate of potas- 
sium ; Bulley warning against the indiscriminate employ- 
ment of the latter ; McDonald, Bass' ale and quinia, with 



ITS HISTORY. 21 

the local application of muriatic acid ; Bouchut, removal of 
the affected portion of the tonsils, and internally glycerin, 
by which method of treatment he anticipates, with his 
usual enthusiasm, a prevention of croup of the larynx, and 
that the wound left after tonsillotomy will not become 
diphtheritic. Soon after he reports a case of croup in 
which restoration of the voice followed the introduction 
of a tube into the larynx. Borland publishes a fatal case 
of croup arising after amputation of the tonsils. 

We shall more than once be obliged to refer back to 
the early history of the pathology and therapeutics of 
diphtheria. The former is in part a new creation, the 
latter greatly improved. For, however greatly the value 
of disinfecting agents, as the sulphites, carbolic and sali- 
cylic acids, administered internally, may be over-estimated, 
yet certain indications for their employment will ever 
remain, and new fields of action be opened to them. In 
the matter of local disinfection, a vast region of usefulness 
and benefit is at their disposal. I shall, however, not discuss 
these points here, as I propose dwelling on them in con- 
nection with the subject of treatment. 

I also refrain from giving a detailed history of diphtheria 
for the past twenty years. It would be a monotonous and 
exceedingly ungrateful task. A great part of that history 
is but a repetition of what has been previously observed 
and reported. Fortunately, however, the ablest minds 
were engaged on the same topic. It is mainly the German 
literature which became, however, enriched by the results 
of investigation in pathology, rather than by the further 
addition to the already enormous category of remedial 
agents. To Virchow we are indebted for recognizing 
different forms of diphtheritic invasion, which, according 
to the depth of their seat, are deserving of different terms. 
The genuinely diphtheritic form extends into the mucous 
membrane, the so-called croupous lies on the surface there- 
of. In the former, the exudation occurs into the tissues 
of the mucous membrane, which thereby becomes de- 



22 A TREATISE ON DIPHTHERIA. 

stroyed ; in the latter, the mucous membrane remains 
intact, and is at the utmost deprived of its epithelium by 
the stripping off of the pseudo-membrane. This difference, 
between death of the tissue on one hand, and an exudation 
of fibrin superficially on the other, soon came to be believed 
in, however, as essential and vital ; even the best text-books 
willingly looked upon diphtheria and croup as heteroge- 
neous, though Virchow himself never committed himself 
to such heterogeneity, but only to divers modes of devel- 
opment.* E. Wagner, however, sought for evidence to 
prove that the two diseases were identical in character, 
and were only apparently distinct, owing to the difference 
in localization and, let us add, in clinical symptoms. He 
found the explanation of the diphtheritic process in a rapid 
granular degeneration and an equally rapid reproduction 
and renewed decomposition of epithelial cells. While 
Wagner attached the greatest importance to the local 
affection, Buhl endeavored to explain the latter by presum- 
ing a constitutional disease which produces lesions in dif- 
erent parts of the body, after the manner of the eruptive 
fevers. According to the latter view, the general infection 
would be looked upon as the essential feature, and the 
granular metamorphosis of the submucous connective tis- 
sue, which, by compression of the blood-vessels, leads to 
death of the tissue, as the result of the constitutional 
disorder. In contradistinction to the view that diphtheria 
is a general disorder with localized lesions, arose that 
which founds all miasmastic and infectious diseases on the 
presence of living organisms. Beginning with Salisbury, 

* The American profession has been greatly influenced by two text-books, 
those of Niemeyer and of Vogel, in regard to this supposed difference between 
croup and diphtheria. To say that the only difference between two foims of 
disease, which unfortunately had different names, consists in the fact that 
the morbid process in the one is found on the surface ; in the other, a little 
below the surface — while it is admitted that the histological condition is the 
same — speaks for an exaggerated tendency to classify and subdivide. It is 
just these chapters on croup and diphtheria in the very same text-books which 
leave more to desire than any other. 



ITS HISTORY. 23 

who, with marvellous rapidity, recorded hosts of micro- 
scopical parasites, to which he as quickly assigned names, 
and not ending with Hallier, the search for minute organ- 
isms was pursued with excessive assiduity. 

So agreeable and tempting did it appear to unveil with 
one supreme effort the mystery attaching to miasmatic 
and contagious affections that literature became flooded 
with "communications" and "preliminary remarks." At 
the same time, however, a series of earnest and conscien- 
tious investigations were recorded. Hiiter, Tommasi, and 
Oertel, the first rather enthusiastically, the latter more 
coolly, prove as the results of their observations and exper- 
iments that diphtheritic membrane, the blood, and certain 
of the tissues are the abode, in diphtheria, of bacteria, 
which, in their opinion, constitute the etiological factors 
of the disease. The investigations of Trendelenburg, 
Nassiloff, Recklinghausen, Waldeyer, Eberth, Klebs, and 
many others have amply enriched the literature bearing 
on this theory. According to it, diphtheria is an exclu- 
sively parasitic disease resulting from local infection, the 
bacteria being either the essential morbific element, as is 
held by some, or the carriers of the diphtheritic poison, 
according to the view of others. Fortunately this theory, 
so agreeable in itself, and apparently consistent with the 
exact and mechanical phenomena of nature, has received 
some wholesome check by the labors of Hiller, Curtis and 
Satterthwaite, Billroth, and others. Above all, be the 
bacteria a frequent, nay even a constant accompaniment 
of accidental wound diseases, and the vehicles of septic 
poison, we may still deny them an independent morbific 
power. In his great work on coccobacteria, Billroth asserts 
that even in pyaemia and septicaemia the existence of 
bacteria in the blood cannot be verified, and Charlton 
Bastian denies that the poison of infectious diseases is 
endowed with vital powers. This subject, however, will 
claim our attention in another chapter of this book. 
Whether the present disharmony in regard to the bacteria 



24 A TREATISE ON DIPHTHERIA. 

question will tend to a satisfactory interpretation of the 
diphtheria problem in the sense of the exclusive and radi- 
cal parasitists can hardly as yet be answered in the affirma- 
tive. I am inclined to deny it. At all events, it does not 
appear safe to go any further than Billroth does in his 
remarks on some forms of diphtheria (Allg. Chir. Pathol, 
u. Ther., 8th Ed., 381). 

" In the pulpous mass of muco-salivary diphtheria (ex- 
tensive diphtheritic destruction of the cheeks, etc., after 
operations on the jaws), and in the urinary diphtheria, 
micrococci and streptococci can always be found ; they 
are met with as constantly in the secretions about the 
teeth and in the coating of the tongue, as well as in 
every specimen of ammoniacal urine, but appear to 
multiply with marvellous rapidity in the above-mentioned 
pulpous mass. The contagion peculiar to this mass 
could not as yet be separated from the micrococci, and 
the latter may, therefore, be presumed to possess, or be 
connected with, the contagious zymotic element ; it has 
not yet been proven that every micrococcus, whatever its 
source \ may originate this element, but many observations 
demonstrate that these organisms may easily absorb certain 
contagious substances and hence act as carriers of contagio?t 
and ferments. For example, if the cornea of a rabbit be 
inoculated with fluids containing the micrococcus, the 
coccus will fructify, as demonstrated by the interesting ex- 
periments of Nassiloff, Eberth, Leber, Stromeyer, Dol- 
schenkow, Orth, Frisch, and others ; in some cases (where 
it is not accompanied by harmful substances) its action is 
principally an irritant one, separating the lamellae of the 
cornea, so that the little coccus-colony is by degrees en- 
closed by a collection of pus and ultimately expelled with 
it ; in other cases again (where the inoculated material is 
possessed of very deleterious qualities), the entire cornea 
becomes gangrenous in twenty-four hours, although the 
coccus-formation have barely reached the degree of development 
that characterized the condition previously described. 



ITS HISTORY. 25 

Finally there are cases in which the small coccus prolifera- 
tion excites no reaction in the cornea, but soon disappears 
without leaving any traces behind ; in fact, this is the rule 
where inoculations are undertaken on the cornea of dogs. 
From this it may be inferred that the intensity of the inflam- 
matory reaction produced by such contagious elements and the 
mode of its production are not dependent on the coccus formation 
as such, but on whether the elements which it brings with it 
are deleterious or otherwise. 

SUMMARY. 

Aretaeus is the first whose description of diphtheria has 
reached us. 

Asclepiades practised scarification of the tonsils and 
laryngotomy. 

Cselius Aurelianus recognized diphtheria of the pharynx 
and larynx and the diphtheritic paralysis of the soft palate. 

Frequent epidemics are known to have taken place in 
the second half of the sixteenth century over the larger 
part of Europe. 

Diphtheria of the skin and of wounds was described by 
Herrera in 15 15. 

Communication of diphtheria through a wound in the 
finger is reported by Mercado in 1608. 

An autopsy was made in 1642, and membrane found in 
the larynx. 

The suffocative, asthenic, and paralytic forms of diph- 
theria were described by Heredia in 1690. 

The first cases known in America occurred in Roxbury, 
Mass., in December, 1659. About that time, and mainly 
about 167 1, the disease was very prevalent. It recurred, 
1735, in New England, and never disappeared for any 
length of time until the beginning of this century. The 
main writers during this period are Douglas, I. Dickinson, 
Cadwalader Colden, Samuel Bard, Jacob Ogden, John 
Archer, Peter Middleton, Richard Bailey. 

Samuel Bard proved the identity of all forms of diph- 



26 A TREATISE ON DIPHTHERIA. 

theria, cutaneous, pharyngeal, nasal, laryngeal, tracheal. 
So did Bretonneau fifty years later, and Trousseau, Louis, 
Rilliet and Barthey, and all the great clinicians. 

Contagiousness was never doubted, but mainly sustained 
by Bourgeoise in 1823. 

Virchow discriminates the catarrhal, croupous, and ne- 
crobiotic forms, 1847. 

Graefe describes diphtheria on conjunctiva and cornea 
in 1854. 

The main objects of the scientific literature of the sub- 
ject in the last twenty years have been the microscopical 
histology and etiology, besides the reports of cases, epi- 
demics, and therapeutics. 



ETIOLOGY. 27 



CHAPTER II. 

ETIOLOGY. 

Diphtheria is pre-eminently a disease of early life ; in this 
respect it is said to differ from the genuine fibrinous bron- 
chitis, which by some is held an absolutely different 
disease and stated to occur but rarely in children. But 
even this statement is probably incorrect. In the single 
spring of 1879, I have m et with four cases of fibrinous 
bronchitis in children under three years of age. The 
number of cases of diphtheria in adult life is not very 
large, while in old age it is very small. Of 501 deaths in 
Vienna in 1868, only one had reached the age of sixty -two ; 
of more than 250 cases in which I performed tracheotomy 
— beside a young physician in New York, whom I saw 
during his illness, and on whom tracheotomy was per- 
formed by a colleague at his dictation, though against 
indication — but two were over thirteen years old. One of 
them was a male of fifty-five years, with ossified tracheal 
cartilages, who perished from gangrenous and septic 
diphtheria and pneumonia thirteen days after the opera- 
tion. The other was a lady of thirty-odd years, rather stout 
and anaemic, but enjoying tolerable health withal, who had 
given birth to six children, four of whom were living. 
December 16th, 1876, she experienced a sensation of chilli- 
ness and malaise, but did not think it of sufficient import 
to inform her physician, whom she had consulted in refer- 
ence to a sick child that very day. On the evening of the 
1 8th inst., she felt very sick and began to suffer from pain- 
ful deglutition. Dr. Conrad was called on the following day 
and diagnosticated diphtheria on both sides of throat, 



28 A TREATISE ON DIPHTHERIA. 

with moderate fever. On the 20th, I saw her with him. 
Temperature about 102. 5 F., isolated diphtheritic deposits 
on both tonsils, and a moderate swelling of the cervical 
lymphatic glands of both sides. 21st: No longer simple 
gray deposits, but a dense membrane covered the tonsils, 
extending over the entire uvula and invading a portion of 
the posterior wall of the pharynx. On the 22d, the mem- 
brane was thicker, denser, and had extended forward over 
one-third of the soft palate and covered the entire visible 
portion of the posterior wall of the pharynx. That evening 
slight dyspnoea was experienced by the patient. At eight 
o'clock on the morning of the 23d, tracheotomy had to 
be resorted to. It was performed under chloroform, and 
owing to the displacement of the trachea by the swelling 
of the thyroid body, it was accompanied by the loss of 
several ounces of blood. Fifteen minutes after the opera- 
tion a cylindrical mass about two inches long became 
loosened and was expectorated ; judging from its diameter, 
it came from one of the bronchi. On this and succeeding 
days, portions of membrane were cast off. On the 23d, a 
feather introduced through the canula, by contact with 
the mucous membrane immediately below the lower end, 
gave rise to coughing. On the 24th coughing could only 
be excited by carrying the feather three inches lower 
down. During that day the dyspnoea, in spite of frequent 
inhalations of oxygen through the canula, was painful to 
witness. One-third of a grain of morphia was injected 
hypodermically at seven o'clock in the evening in order to 
relieve the sufferings of the patient. She died at ten o'clock. 
The treatment had consisted in half-grain doses of carbolic 
acid every half- hour, in the administration of chlorate of 
potassa and chloride of iron at similar intervals, in disin- 
fectant injections into the nostrils, in half-hourly intervals, 
of a weak solution of carbolic acid (1 : 50-100) and a spray 
of a solution of lactic acid (1 : 24) directed through the 
canula into the trachea and bronchi, every five or ten 
minutes. 



ETIOLOGY. 29 

I do not know that sex exerts any predisposing- influence 
over diphtheria, yet of the 600 cases or thereabouts of 
laryngeal diphtheria in which I either personally performed 
tracheotomy, or observed the progress of the disease in 
the practice of others, I found the majority in males and 
the recoveries in inverse proportion to the number thereof ; 
the mortality being greater among boys. As far as age is 
concerned, most zymotic diseases are seen most frequently 
in children. This has been explained by some on the 
ground that these diseases, particularly scarlatina and 
whooping-cough, less constantly measles, occur but once 
in a lifetime, and therefore the number of adults that can 
still be attacked by those diseases is proportionally small. 
Typhoid, too, is by no means of rare occurrence, but its 
invasion is, in my opinion, intimately connected with cer- 
tain anatomical and physiological conditions. That part 
of the lympathic system, Peyer's patches, which plays so 
important a part in the symptomatology of typhoid, is but 
little developed in childhood. In addition to this, the act 
of respiration up to a certain age is performed very super- 
ficially, while at the same time the tissue metamorphosis is 
quite active. In this way the noxious elements are but 
slowly taken up by the lungs, the rapid metamorphosis of 
tissue brings about a speedy elimination of the poison, the 
intestinal symptoms assume no importance, the entire 
course is a mild one ; in fact all the milder the younger the 
patient. The new-born and infants at the breast rarely 
take the disease. I saw typhoid in a child of seven months 
still at the breast. I presented the specimen from a child 
of sixteen days at the Obstetrical Society of New York, 
seven years ago, typhoid having occurred soon after birth. 
It is the only specimen that I have ever seen and is one of 
the very few that have ever come to light. This subject 
of typhoid fever I have taken as an example to prove the 
dependence of a morbid process on certain anatomical and 
physiological conditions. The same holds true for diph- 
theria. Children exhibit a greater predisposition toward 



30 A TREATISE ON DIPHTHERIA. 

the disease than adults, if we except those under ten 
months. Where the disease has, however, occurred pre- 
vious to the seventh or eighth month, the greater num- 
ber of cases has been found under three months. Tigri 
reports the disease in a child of fourteen days. A child 
of fifteen days was seen with diphtheritic laryngitis and 
oesophagitis by Bretonneau, one of seventeen days by 
Bednar, of eight by Bouchut, one of seven days by Wei- 
kert ; Parrot mentions several cases, and Siredey (These, 
Paris, 1877) reports eighteen cases of diphtheria in the 
newly born. They occurred in the Hospital Lariboisiere 
in the spring 1877, and were probably infected by the 
nurses of a neighboring child's asylum. Membranes were 
found on the soft palate,, tonsils, or larynx, and also on 
both pharynx and larynx. One case occurred where the 
posterior nares alone were affected. I have met with 
three cases of diphtheria of the pharynx and larynx in the 
newly-born myself. One of these became sick on the 
ninth day after birth and died on the thirteenth day ; the 
other died on the sixteenth day after birth ; the third was 
taken when seven days old, and died on the ninth day. 
A very young child on whom I performed an operation 
for complicated hare-lip was reported to me as dying 
from diphtheria, a few days after, by a young colleague 
in attendance. It turned out to be muguet, however, and 
subsided under the appropriate treatment. The predispo- 
sition toward diphtheria during childhood* seems to be 
explainable by several circumstances of the process, whether 
it develop from within or be derived from external sources. 
The mucous membrane of the mouth and pharynx in the 
child is more succulent and softer, and frequently the seat 
of a congestive and inflammatory process. The nasal cavi- 
ties are small and frequently affected by catarrhs, the buc- 

* W. N. Thursfield (L. Lancet, Aug. 3d, 10th, 17th, 1878) collects 10,000 
cases of diphtheria in England, between the years 1855 and 1877. Of these 
were 90 p. m. under a year, 450 p. m. from 1-5 years, 260 from 6-10, 90 from 
11-15, 50 from 16-25, 35 from 26-45, 2 5 P- m - were 45 years and over. 



ETIOLOGY. 31 

cai cavity often the seat of catarrh and of stomatitis, and 
insufficient cleanliness leads here to irritation of the rau 
cous membrane. Any abnormal state of the mucous 
membrane, with the exception of an atrophic condition 
and cicatricial changes, affords an excellent abode for 
diphtheria. The tonsils are proportionally large ; in fact 
we rarely see the tonsils in children completely shel- 
tered by the arches of the palate. On the other hand, the 
pharynx is anything but spacious, and while the protuber- 
ant condition of the tonsils affords a resting-place for the 
disease, the remaining space is so small that it becomes a 
source of uneasiness to the well, in many instances, and 
very much more than that to the child during diphtheritic 
tumefaction. Furthermore we must take into considera- 
tion the large number and size of the lymphatics, which 
can be more easily injected in the child than in the adult, 
according to Sappey, and the fact of greater intercommu- 
nication amongst the lymphatics and between them and 
the system. For S. L. Schenck has found that the network 
of lymphatics in the skin of the newly born, at least, are 
endowed with stomata, loopholes through which the lymph- 
ducts can communicate with the neighborhood, and vice 
versa (Mittheil. aus d. Embryol. Instit., I., 1877). These 
circumstances, although they may have no influence in call- 
ing the disease into existence, yet assist in its develop- 
ment and in adding to the severity of the symptoms. 

On the other hand, while the above reasons go to prove 
that diphtheria attacks children by preference, there is 
again an anatomical and physiological condition, to wit, 
the free slightly acid secretion of the mouth, beginning 
with the third month, that acts as a hindrance to the fre- 
quent occurrence of diphtheria after the third month. A 
poison or poisonous product of whatever nature can less 
readily find a hiding-place so long as it can be readily, we 
might always say must surely be, washed away. An im- 
portant etiological consideration is the fact of having had 
the disease previously. We can cite a host of zymotic 



32 A TREATISE ON DIPHTHERIA. 

diseases the occurrence of which once, serves as a protec- 
tion against future attacks. Not only can no such security 
be expected after one attack of diphtheria, but cceteris 
paribus, the disease shows a preference for those who have 
survived a previous attack. The statement that only the 
mild cases with but slight elevation of temperature and 
freedom from severe constitutional symptoms are likely to 
suffer a relapse is founded on error. True, I have more 
frequently seen relapses after mild cases — which fortunately 
are in the majority — but the disease has also recurred 
where originally high fever and an extensive lymphaden- 
itis proved it to be a severe case. Yet not many can point 
out a child on whom tracheotomy had twice been per- 
formed, as for instance Guersant, whose case has often been 
quoted, and H. Z. Gill (Abstr. of the Rep. of the Spec. 
Comm. on Croup of the 111. State Med. Soc., Chicago, 
1878). He operated on March 21st, 1877, removed the 
tube on the 27th, and the wound was nearly closed on the 
28th. On May nth, the same operation had to be per- 
formed for the same disease, with the same favorable 
result (though the tube was not removed on Sept. 25th, 
1878). Quincke also operated on a boy of one and a half 
years on the 2d of March, 1874, and removed the tube 
after seven weeks; and for the second time on the 12th of 
July, 1875, the tube being required two years and a half 
after (Corresp. Schweizer Aerz., 15th April, 1880). 

As there are individuals, so there are families which 
have a predisposition to diseases, as there are others in 
whom, notwithstanding ample exposure, infection does not 
easily take place. Yet in the families in which diphtheria is 
of frequent occurrence it cannot always be attributed to 
enlarged tonsils and a tendency to pharyngeal catarrh. 
My experience has been similar to that of R6villiod, who 
made this question the subject of a paper read before the 
Geneva Med. Soc, Dec. 1st, 1875. A certain family with 
which I am acquainted lost in the course of six or seven 
years all its younger members with diphtheria of the 



ETIOLOGY. 33 

pharynx and larynx. The children had been born in inter- 
vals of several years. While one child of a few years of age 
would be affected with diphtheria, there would be another 
at the breast. After two children had succumbed to the 
disease at an early age, Dr. Krackowizer performed trache- 
otomy on the third, who also died. Some years later, I 
operated on the fourth child, with the same result. I may 
add that there could be no question of an epidemic or en- 
demic influence, for the cases extended over a number of 
years, and the family had occupied two different houses in 
the mean time, in different parts of the city. One child 
only had never undergone a severe attack of diphtheria, 
but she was six years older than the one who had been the 
first victim of the disease. 

In diphtheria, as in other diseases, sudden changes in the 
temperature of the atmosphere, or of the surface of the 
body, have been looked upon as etiological factors. Yet 
they have occurred from time immemorial without being 
accused of causing an invasion of diphtheria, unless when 
present at the same time as an epidemic. On the whole, 
however, it is true that, while severe epidemics have 
spared no climate or land known to us, the majority of 
cases have occurred in winter and spring, in other words 
at a time when catarrhal disorders are of most frequent 
occurrence. Thursfield, while finding no connection 
between the rate of mortality from diphtheria and the 
amount of yearly rainfall, points to the variation of mor- 
tality in the several quarters of the year. In England, 
the average mortality from diphtheria in the years 1870 
"-1877 was, in the first quarter, 735; in the second, 578; 
in the third, 547, and in the fourth, 750. In Lynn, Mass., 
J. G. Pinkham (Sanitary Condition of Lynn, including a 
special report on diphtheria, Boston; 1877), found 23 per 
cent of all the cases to have taken place in October, the 
smallest number in August. Woizechowski and Asch- 
scharamoff (Mosk. M. Gaz., Nos. 6-8, 1878) counted in 9,858 
cases occurring in the year, 5,579 in September, October, 
3 



34 A TREATISE ON DIPHTHERIA. 

and November. Seitz also finds more cases in October 
than any other month. In my experience, at New York, 
the first quarter of the year yielded more cases than any 
other. But the difference in numbers varies so much with 
the writers, in different countries and climates, that E. 
Besnier's attempt at establishing an "invariable season 
law" for diphtheria (Un. Med., No. 129, 1878) is liable to 
appear like rather too much generalization from the expe- 
rience of one man. Thus looked upon, the influence of 
season on the invasion and course of diphtheria is but in- 
direct and conditional, and may be perhaps, after all, com- 
pared with that exerted by "filth," a term which is lately 
used to express all sorts and forms of nastiness, from filthy 
bodies of men, to their clothes, their habits, their food, and 
the air they breathe, whether polluted by carbonic acid, 
by excrementitious gases, or exhalations of sewers. 

Cases of diphtheria which are traced to exhalations from 
sewers (or even to filthy habits of life) are very frequent. 
Yet typhoid is attributed to the same causes. So is dys- 
entery. Can then foul exhalations produce alike diphthe- 
ria, typhoid, and dysentery ? Do these diseases arise 
from a common poison ? Or is the poison of a treble char- 
acter, so that a part may give origin to diphtheria, the 
other part to typhoid, the third to dysentery ? In a house 
in West 22d street, between Eighth and Ninth avenues, in 
New York, three children and a female help were taken 
sick, two with dysentery, two with typhoid, in the course 
of a month. In the same house, in two of the children, 
diphtheritic sore throats were of frequent occurrence.* 

Have we to deal, in such occurrences, with specific influ- 

* On the other hand, Thursfield shows that fatal diphtheria is mainly — in 
England — an attribute of the country, while typhoid fever belongs to the large 
cities. These, like London, Liverpool, Bristol, have a high mortality of ty- 
phoid fever, while Sussex, Shropshire, Oxfordshire, lose a larger percentage 
of diphtheria. During the years 1870-1877, Liverpool lost at the rate, of a 
population of 100,000, of typhoid fever 104.3, an( i 0I " diphtheria 10.3; Sussex, 
however, of diphtheria 21. 1, and of typhoid fever only 31.5. 



ETIOLOGY. 35 

ences, or only with a lowering of the standard of health, 
thereby affording other morbid influences an opportunity 
to exercise their power ? These questions are still involved 
in darkness and constitute problems the solution of which 
still engages the minds of both individual writers and 
authorities. 

Only recently the results of a careful comparison of a 
large number of cases of diphtheria reported in Massachu- 
setts were formulated as follows : 

i. Diphtheria is contagious, and highly so under certain 
circumstances. It is also infectious, although not to such 
a degree as scarlatina, measles, and small-pox. 

2. The other circumstances being favorable, a moist soil 
assists in spreading the disease, be the moisture a natural 
condition or brought about artificially, and particularly 
when the substratum is of an impermeable nature.* 

3. A positive connection between diphtheria and filth 
cannot be verified, although the latter but adds to the evil 
influence of moisture. The contamination of spring-water 
by human excrements, and of the atmosphere of the bed- 
chamber by the emanations from sewers, require further 
study. Several reports point to septic infection by drink- 
ing contaminated water, but a final opinion on that point 
would as yet be premature. 

4. Cold and dampness constitute an etiological factor in 
children, and in individuals with a predisposition toward 
the disease. Yet the statements concerning wind, temper- 
ature, and weather do not allow of any definite conclu- 
sions. 

5. Other circumstances being equal, natives of Massa- 
chusetts and strangers are affected alike. 

* J. G. Pinkham reports 614 cases of diphtheria' in Lynn, 80 per cent of 
which took place in valleys of brooks, in the vicinity of marshes, where the 
soil was damp and without artificial drainage. The immediate humidity of the 
atmosphere had no influence, however; nor was elevation of any account ex- 
cept in determining the condition of the soil. In all the endangered places 
the subsoil was an impervious clay. 



36 A TREATISE ON DIPHTHERIA. 

6. Differences in the course and termination of the dis- 
ease depend on the idiosyncrasy of the individual or fam- 
ily, on age and on strength. 

7. Atmospheric conditions exert an influence which is 
not yet thoroughly comprehended. 

8. The period of incubation, where it was possible to 
determine it, was about one week. 

9. The invasion was sudden and accompanied by mark- 
ed general disturbances. Death resulted from suffocation 
or collapse. Convalescence was slow. 

10. In adults the disease occurred less frequently, and 
in a milder form than in children. The disease was seen 
in babes of five, seven, and nine months. 

11. As during the prevalence of epidemics of typhoid 
and cholera, we encounter mild fevers and diarrheas, so 
during an epidemic of diphtheria there are always a large 
number of inflammatory affections of the throat. 

For the sake of completeness, I have here given the 
principal points of the official report, even though some 
of them are not exactly in place. 

I believe that it goes just so far in the estimation of the 
value of the etiological factors of the disease as our 
knowledge and experience allow. The assertion that 
diphtheria is a " filth disease," and the oft-repeated discus- 
sions on this point, both publicly and privately, in England 
and America, cause one to be thankful for the above 
modest and sensible resume of our knowledge on the sub- 
ject, which, on that point, has not progressed much since 
that report was published, a few years ago. 

What is the nature of the diphtheritic poison ? Is it of 
a chemical character? Is it organic? 

Already in 1840, Henle expressed his belief in a conta- 
giurn animatum. After morbific processes had already^ pre- 
viously been compared with the phenomena of fermenta- 
tion, Schwann demonstrated the presence of lower organ- 
isms in fermentation and putrefaction. The discovery- of 
the cause of the silk-worm disease by Bassis, of the acho- 



ETIOLOGY. 37 

rion by Schonlein, of the acarus by Simon, of bacteria in 
malignant pustule by Pollender, Brauell, and above all by 
Davaine, in relapsing fever by Obermeier, the teachings 
of Pasteur concerning the conditions under which putre- 
faction occurs, all tended to explain the various infectious 
and contagious diseases, by analogy, in the same way, and 
particularly to stimulate the search for a vegetable organ- 
ism in diphtheria. Buhl was the first to discover schi- 
zomycetse in diphtheritic membrane, but expressed no 
opinion as to the part they played in the process. Hiiter 
found them in the gray diphtheritic covering of wounds, 
in the surrounding, apparently healthy tissues, and in the 
blood. Hiiter and Tomasi found them in the diphtheritic 
membranes of the pharynx and larynx, inoculated them 
on the mucous membranes of animals, and described them 
as small, round or oval, dark-colored, active little bodies. 
The latter observers look upon these organisms as a part 
of the infectious element. Oertel found them in diphthe- 
ritic membrane and in inflamed mucous membranes in the 
lymphatic vessels, lymphatic glands, kidneys, and other or- 
gans ; he considers them at the bottom of the diphtheritic 
process and constituting the contagious element. Nassiloff, 
too, after inoculations in the cornea resulted in an enorm- 
ous multiplication of the microscopic organisms, and their 
appearance with pus-cells in the lacteals, and in the lym- 
phatics of the palate, and even in the bones and cartilages, 
asserts that the development of organisms is the primary 
step in the diphtheritic process. Eberth made successful 
inoculations in living tissues ; the micro-organisms, intro- 
duced into the cornea, proliferated actively and caused an 
inflammation of irritative character in the surrounding tis- 
sue. He asserts, with the positiveness of an evangelist, that 
diphtheria cannot occur without bacteria. Klebs inocu- 
lated the micrococci in pigeons and dogs and demonstrated 
the presence thereof in the blood of the animals after death. 
Orth found them in the pleura, lungs, kidneys, and urinary 
bladder. But what their action is, whether they are 



38 A TREATISE ON DIPHTHERIA. 

directly pernicious, or deprive the body of certain ele. 
ments (as of oxygen in malignant pustule, according to 
Bollinger), or injure mechanically, by acting on the coats 
of the blood-vessels either directly or by means of altering 
the blood, and thus ruling out of existence territories of 
blood-vessels, is a question upon which the principal ad- 
vocates of the parasitic theory have not yet agreed. Even 
Oertel acknowledges the impossibility of explaining the 
manner in which the bacteria act (Ziemssen, Handbuch, II., 
i, p. 581, 2d edit.). This much is positive at any rate, that 
no one has yet proven that the vegetable organisms alone, 
and not other, free or fixed, parts of the diphtheritic mem- 
brane, are the vehicles of the infecting elements (Steu- 
dener) ; and even now the question has not been decided 
whether the bacteria met with in diphthei'ia constitute the 
cause of the disease ; or are a part of the process, or co- 
effects of the poisonous action ; whether they are the 
carriers of the poison, or entirely indifferent entities. 

The most important observations made by those who 
deny a direct etiological connection between micro-organ- 
isms and septic diseases in general, and diphtheria in par- 
ticular, are those of Hiller, and Billroth. The latter has 
proven the morphological identity of the various kinds of 
bacteria, although it cannot be denied that the apparent 
similarity may mask a yet unknown difference. Hiller 
calls attention to the fact that large numbers of micro- 
cocci have been found in the cadaver where death has not 
been the result of septic disease, and also that septic in- 
fection is not always severest where the bacteria most 
abound, but where an extensive chemical decomposition 
or a mass of putrefying tissue is found. This would indi- 
cate that the septic process is rather dependent on chemi- 
cal decomposition than on the presence of bacteria. 

Panum, Bergmann, and Schmiedeberg have isolated 
poisons that contained no bacteria. Rawitsch and many 
others prove that septic infection is not dependent on the 
existence of bacteria. Davaine has shown that an infi- 



ETIOLOGY. 39 

nitely small amount of a chemical poison, free from bacteria, 
can kill quickly. Panum, Billroth, C. O. Weber, and 
Hemmer emphasized the chemical nature of the poison. 
Hiller, by injecting isolated bacteria in large numbers into 
the subcutaneous cellular tissue of dogs and rabbits, pro- 
duced a slight local swelling, but neither abscesses nor 
fever. Even injected into his own subcutaneous cellular 
tissue, it produced but a slight oedema ; in subcutaneous 
wounds which would not have suppurated otherwise, 
only oedema was produced. Experiments with the true 
bacteria of putrefaction led to a similar result. Injected, 
into hens' eggs, the latter did not become rotten. There 
must be, therefore, elements of putrefaction which are inde- 
pendent of bacteria, and Pasteur acknowledges the truth of 
this remark. So much is true, that bacteria do not receive 
their albumen in the form in which its exists in the tissues, 
but it must be first dissolved by the putrefactive process. 
Therefore, in diphtheria the gangrenous process cannot or 
need not depend on a direct " devouring " of the tissue. 
Hiller, from observing that, in accidental diseases of 
wounds, bacteria are a frequent and probably constant 
accompaniment, and that their most active proliferation en- 
sues after death, believes that they fill themselves with the 
septic poison of the decomposed tissues, and then transport 
it further, in this way exerting a local as well as a general 
action ; and also that it may even be in their power to re- 
produce the poison, but that they do not carry an inde- 
pendent danger of their own, or essential to them, and, as 
parasites, may be considered harmless. If any organic 
substance capable of undergoing putrefaction be separated 
from the original tissue, it will certainly float in the air in 
the form of an atom of dust, yet an infection need not 
always result. But these elements of putrefaction are 
probably not bacteria, but some other molecular body 
accompanied or not by bacteria. Besides, we cannot yet 
assert with conviction that the agents of infectious disor- 
ders are actually solid, still more, organic bodies. As they 



40 A TREATISE ON DIPHTHERIA. 

may just as well be fluid or even gaseous, the nature of 
infection is still in the dark. 

Billroth, too, holds that plants cannot decompose or- 
ganic compounds, and can only digest gases already 
formed ; that bacteria only serve to excite an inflamma- 
tion when they themselves are infected, and if introduced 
into the cornea they assume the characteristic form of the 
fungus and may then prove innocuous ; that cocco-bac- 
teria, a foul secretion, and fever are not always found 
together. " The secretions from the earlier stage of in- 
flammation have a more powerful phlogogenous action 
than those of a later period, and the action of the micro- 
coccus does not depend on its mechanical influence on the 
tissues, or on its presence there in a living form, but on 
whether it is the means of conveying irritating elements 
into the tissues or not." (Arch. f. Klin. Chir., XX., 414.) 
Ehrlich, also, in his experiments on erysipelatous skin, 
found that the commencing inflammation was accompanied 
by the formation of a large number of micrococci, which 
gradually disappeared as the process progressed. In addition, 
when fluids containing cocco-bacteria were injected into 
the skin, micrococci, and not scattered or closely clustered 
bacteria, came into view. True, the latter were seen in 
small blood-vessels, but a cellular infiltration was rarely 
observed to surround their abode. Fibrinous thrombi 
were not by far present on every occasion in the smaller 
blood-vessels, and therefore had probably not formed 
during life, or if so, only in the last moments. That cocco- 
bacteria are transferable from one part to another is self- 
evident. Their minuteness, and the fact that small emboli 
can traverse the pulmonary circulation and be deposited 
in remote organs, would indicate and in fact presuppose 
their appearance in the lymphatic channels and glands. 
Their circulation in the blood-vessels would be freer than 
in the lymphatic system, where the glands act as impedi- 
ments and filters. But if we assume that the transporta- 
tion of bacteria goes on in the same manner as that of 



ETIOLOGY. 41 

emboli, we should find the former at the place where the 
arteries become capillaries, whereas they are found in- 
stead in the small veins. Hence this fact would speak 
rather for a rapid formation after death than for a pro- 
cess occurring during life. 

The presence of cocco-bacteria in the blood during life 
has not once been proven, not even in pyaemia or septicae- 
mia. Yet their being swept into the lungs with the atmo- 
spheric air is indisputable. It would, therefore, seem as 
though living blood had a greater tendency to destroy 
bacteria than to allow itself to be decomposed by them. 
Not only, however, would it seem so, but P. Grawitz 
(Virch. Arch., vol. 70, p. 546) proves that sporules do 
not grow in the (tissue and) blood, but that they are in 
part dissolved, in part eliminated through the kidneys, 
and that this result is accomplished through the combina- 
tion of the following four factors, viz., the elasticity of 
the blood, its constant motion, the absence of oxygen in 
sufficient quantity in the circulating blood, and the pres- 
ence of living animal cells. All of these factors appear to 
be of great importance. Thus it is that, where the con- 
stant motion of the blood and the animal living cells are 
not present (as in the anterior chamber of the eye, or 
in the humor vitreous), a rapid proliferation and accumu- 
lation of bacteria can take place. They are also known 
to increase rapidly, and emigrate into the liver, when de- 
posited in the abdominal cavity. 

The destruction of bacteria going on in the circulating 
blood, into which they may have penetrated, accounts for 
some microscopical facts in connection with (actually or 
apparently morbid) blood. Their remnants are probably 
the pale and dark particles which are discovered in the 
blood, alongside the red and white blood -corpuscles. 
They could not be identified as micrococci, while in the 
tissue they are more recognizable. In autopsies, they 
have been found in the urinary tubules, pressing forward 
and piercing the walls, not occupying a nidus of inflamma- 



42 A TREATISE ON DIPHTHERIA. 

tion, however, and probably, are even here a post-mortem 
phenomenon. A direct necrosis or inflammation, by the 
inoculation of diphtheritic elements, can only be produced 
in the cornea, as was shown by Recklinghausen, and par- 
ticularly Eberth. Besides, there is nothing characteristic 
in the cocco-bacteria of diphtheria, with the exception, per- 
haps, of their browner color, to justify their being looked 
upon as a distinct variety, certainly not as another spe- 
cies. It is more likely that a difference of action is not so 
much to be sought for in a different parasite, as in the 
peculiarity of the corneal tissue. When fluid containing 
cocco-bacteria was injected into the eye of a rabbit, in 
twenty-four hours the eye was destroyed. If injected into 
the eye of a dog or guinea-pig, only a slight inflammation 
resulted (Billroth and Ehrlich). If these experiments 
were continued on a larger scale, we might eventually, 
by analogy, ' infer and even prove, that the immunity 
against certain diseases enjoyed by some animals is 
owing to peculiarities in the very structure of their own 
tissues." In a similar manner I shall prove hereafter that 
even peculiarities and variations in the tissue and epithe- 
lium of the human body give rise to different shades and 
variable clinical symptoms in the diphtheritic processes. 

The views of Curtis, Satterthwaite, and Charlton Bas- 
tian fully agree with those of the above observers. Bas- 
tian, from the occurrence of fermentation and putrefac- 
tion without the presence of bacteria (since the analogy 
between contagion and putrefaction must be maintained), 
asserts the innocuousness of a multitude of bacteria in the 
blood, in all parts of the body and in open wounds. He 
testifies to the inverse proportion between the virulence 
of some septic fluids and the number of bacteria con- 
tained therein, and to the impossibility of depriving a 
septic fluid of its active properties by boiling and the ad- 
dition of alcohol. He is rather inclined to look upon 
bacteria as an effect of the disease than as a cause. 

* Compare p. 25. 



ETIOLOGY. 43 

Curtis' and Satterthwaite's careful and judicious ex- 
periments led to the following conclusions (Edward Cur- 
tis and Thomas E. Satterthwaite, Report on Investiga- 
tions into the Pathology of Diphtheria) : 

I. Inoculation of diphtheritic membrane into the mus- 
cular tissue of the rabbit produces severe local lesions, 
and even constitutional disturbance and death. But these 
effects differ so in their pathology and clinical history 
from diphtheria in the human subject that there is no 
warrant for defining them as diphtheria, or for applying 
conclusions drawn from observation of this inoculation 
disease in the rabbit to the case of diphtheria in man. 

II. Effects exactly similar to the foregoing, and of equal 
severity, can moreover be produced by inoculation of a 
material not only non-diphtheritic, but non-infectious to 
the human subject, under conditions where diphtheritic 
membrane is infectious, i. e., when brought into contact 
with the mucous membrane of the mouth and throat. 
The material referred to is the pulpy scraping of the up- 
per surface of the healthy human tongue. 

III. Effects generally similar to the foregoing, though 
not of equal intensity, can furthermore be produced by 
inoculation of a putrescent matter which is not even of 
immediate animal origin, namely, Cohn's fluid, allowed 
to spontaneously decompose (an aqueous solution of am- 
nionic tartrate, potassic and calcic phosphates and mag- 
nesic sulphate). 

IV. The foregoing inoculation effects are not due to 
simple mechanical irritation, for inoculation of sand pro- 
duces no effect whatsoever. 

V. Thorough filtration of a proven virulent aqueous in- 
fusion of diphtheritic • membrane, or of putrid Cohn's 
fluid, removes the infectious property of the same. 
Hence in such diphtheritic infusion the poisonous quality 
probably inheres in some particulate thing, from which it 
is not separable by the action of cold water. 

VI. Thorough trituration of proven virulent diphthe- 



44 A TREATISE ON DIPHTHERIA. 

ritic membrane and tongue-scrapings, with a high per- 
centage of salicylic acid, fails not only to remove, but 
even markedly to modify, the intensity of the infectious 
quality of those substances. Hence, since salicylic acid, 
in even a minute percentage, is capable of permanently 
suspending the vital activity of bacteria, the inference is 
that the infectious quality of diphtheritic membrane upon 
the system of the rabbit is not correlated to the vital ac- 
tivity of the bacteria present in such membrane. 

VII. If, as is not improbable, the noxious principle in 
diphtheritic membrane which produces in rabbits the 
effects described, be the same with, or even analogous to, 
the principle which produces diphtheria in man by direct 
infection, then the conclusion of VI. will apply to the in- 
fectious quality of such membrane, in its relation to the 
reproduction of diphtheria in the human subject. If this 
be the case, it follows as an important practical corollary 
that there is no theoretical ground for assuming that prevent- 
ing the bacteria of a diphtheritic patch from making their 
way tJirongJi the underlying mucous me7nbrane will, per se, 
prevent general diphtheritic infection of the system. 

VIII. There is no relation between inoculable viru- 
lence of a diphtheritic membrane and the period, within 
three days, that has elapsed between the detachment of 
the membrane and the inoculation with the same, nor be- 
tween inoculable virulence and gross amount of bacteria 
present in the membrane. 

IX. There is a rough relation between inoculable viru- 
lence of a diphtheritic membrane and the severity of the 
original case of diphtheria, so far as this can be estimated 
by the termination of the case in death or recovery. 

But, the investigators add, in the true spirit of men who 
are looking for facts and not for the upholding of a precon- 
ceived theory, that " it must be distinctly understood that 
these nine propositions are not put forth as proven, but 
merely as the results of our experiments and observations, 
so far as the latter go, stated in abstract form. Before the 



ETIOLOGY. 45 

propositions can be considered proven as truths, a large 
number of corroborative experiments will have to be 
made." 

A similar result was obtained by Burdon Sanderson. 
The clay filter undoubtedly absorbs the granular contents 
of the fluid. These particles are either soluble or in a 
state of suspension in the form of minute granules, in the 
fluid which is contaminated by their presence, and although 
it may seem clear to the naked eye, yet will be found, when 
examined microscopically, to contain minute granules. 
Septic fluid containing such granules was exposed to the 
action of alcohol and boiling, both of which are fatal to 
bacteria. The fluid remained septic notwithstanding, even 
although, while the circumstances were favorable, no bac- 
teria developed therein. Furthermore, no bacteria could 
be propagated from the granular bodies. 

The experiments of Weissgerber and Perls likewise af- 
ford no great encouragement to the partisans of the para- 
site theory. They studied the influence, on micrococci, 
of a narrowed calibre of veins, and for the present still 
left to further discussion the question, whether the clus- 
ters of micrococci found in inflamed tissues, as in erysipe- 
las (Lukomsky), and in small-pox (Weigert), are the result 
of the presence of the exudation which would have the 
effect of retarding circulation. However, they seem to 
incline to the opinion that, when micrococci are found 
in the glomeruli of the kidney, their presence is to be ex- 
plained by embolism, and when observed in the capillaries 
and veins, by stagnation. But they acknowledge that there 
are cases in which micrococci are found in the glomeruli 
from stagnation also. Many have inclined to the view 
of an accumulation of bacteria (and then only a prolifera- 
tion) in embolism, as Liicke asserts in connection with in- 
fectious periostitis (Deutsche Z. f. Chir., 1874, vol.4). But 
experiments in no wise substantiate this, for the above- 
mentioned observers having, in a number of animals, nar- 
rowed the calibre of the renal vein, and either during, 



46 A TREATISE ON DIPHTHERIA. 

immediately before, or immediately succeeding the opera- 
tion injected into the blood in some cases aniline-blue 
in a state of finest dilution, in others isolated bacteria taken 
from a putrefying fluid, could not find the injected sub- 
stances to any large amount in the corresponding kidney, 
although their presence could be detected in the tissues, 
and in considerable amount in the other kidney, the circula- 
tion of which had been undisturbed. The above results 
ought to throw a damper on the hopes of those who infer 
from the presence of micrococci in the kidneys that they 
are the cause of desquamative nephritis, as was but re- 
cently the case with Reimer. Least of all can we pardon 
an author for declaring a somewhat obscure case of renal 
disease to be diphtheritic only because he happens to find 
micrococci in the kidneys; while the whole question is 
still sub jadice. 

After all the foregoing, when we compare all the evidence 
adduced for and against the etiological signification of bac- 
teria as originators of infection, we can come to no affirm- 
ative conclusion. That the lowest organisms might be 
important, etiologically, in the infectious diseases was, from 
the start, a plausible assumption. It has not been possible, 
however, to find special organisms for different diseases — 
with the exception perhaps of certain stages of malignant 
pustule and relapsing fever. At all events, their manner 
of action is hypothetical ; to assert that infection is anal- 
ogous to the process of putrefaction is equivalent to 
leaving both putrefaction and infection unexplained. I 
do not think that even to-day we are justified to go beyond 
this statement of Panum's concerning our present knowl- 
edge on the subject : " It is a matter of rejoicing that physi- 
cians in general have come to the conclusion that certain 
microscopic organisms, be they considered vegetable or 
animal, and designated as bacteria, fungi, monads, micro- 
cocci, or vibriones, do not exist merely in the minds of 
theorists as causes of disease, but are in reality enemies 
that must be combated with all the known, efficient weap- 



ETIOLOGY. 47 

ons in our possession. But while thus rejoicing, it must 
be borne in mind that we have but a feeble insight into 
the relation between these organisms and diseases, and in 
order to effect that much desired advance in scientific 
knowledge — a matter of considerable importance in the 
practice of medicine — it is necessary, not only to grasp at 
isolated data, but carefully and deliberately to observe 
and study all the facts before us ; and even to devote some 
attention to those which would tend to prove that there 
are bacteria and fungi which, under certain circumstances, 
are perfectly harmless, and that even some of the malig- 
nant ones among them do not commit all those outrages 
with which they are charged, directly and personally." 
To what extent this is true is perhaps best illustrated by 
the results of A. Hiller's investigations, published in his late 
work on Putrefaction (Berlin, 1 879). He cannot be accused 
of experimenting hastily or writing too early. Thus it has 
not happened to him to be compelled to change opinions 
too often. In my contributions to the pathology, etc., of 
diphtheria (Amer. Jour. Obst, Feb., 1875), I referred to 
his position in the bacteria question ; and I am glad to be 
able to say that in his late large work he can afford to 
state, not as his opinion, but as the result of his studies, 
that the " septic or putrid " poison contained in putrefying 
materials is a chemical substance formed by the process 
of putrefaction ; that its efficacy does not depend at all on 
the life or presence of organisms ; that the symptoms of 
septic and putrid infection are observed without the co-op- 
eration of bacteria or micrococci ; that bacteria cannot be, 
per se, the poisonous principle in putrefying substances, 
but that this must be a material adhering to (possibly even 
produced by) the organisms, which can be separated from 
them by a washing process ; that there are numerous cases 
in which the multiplication of micrococci in the living 
body was uninjurious, and but the result of the disease ; 
and that any progress of our knowledge concerning the 
whole subject will depend on renewed investigations of 



48 A TREATISE ON DIPHTHERIA. 

the metamorphosis of the minute organisms, and of their 
share in the chemistry of the putrefaction process. 

In regard to diphtheria in particular, the parasitists have 
always proceeded with so much enthusiasm that many 
promises which were made could not be fulfilled, and 
many proofs which were offered could not be presented. 
Klebs does not prove, he begs, his case when he insists 
upon it that the diagnosis of diphtheria depends on the 
presence or absence of the microsporon diphtheriticum. A 
case is not settled by the non-acceptance of a diagnosis for 
no other reason but the absence of a parasite, the presence 
or accumulation of which is not expected or claimed as 
pathognomonic by hosts of others ; nor has the promise 
infallibly to produce the disease on man and animals by 
inoculation, to reproduce the disease by ''synthesis," been 
made good to the extent promised ; nor is the large num- 
ber of journal essays and contributions apt to sweep away 
the critical judgment of the profession. Our experience 
has been that the very latest microscopical investigations 
of the most prolific writers always claimed to be unim- 
peachable revelations. One of the most energetic para- 
sitists, L. Letzerich, according to whose dicta the specific 
parasites of diphtheria, of whooping-cough, of "typhoid 
fever could be diagnosticated under the microscope as 
though they had been labelled, admits now (Arch. f. ex- 
periment. Pathol, u. Pharmacol., vol. XII., 1880) the great 
difficulty of discriminating the specific schizomycetae of 
diphtheria, infectious croupous pneumonia, epidemic influ- 
enza, and typhoid fever in their accumulations in the 
human and animal body. While last year there were no 
difficulties whatsoever in their ready diagnosis, this year 
the morphological differences are better appreciated by 
an artificial propagation and proliferation in the blood 
taken from the sick, I cannot but feel that the very pro- 
gressive part of the profession is also the conservative 
one, and will not readily admit that a few microscopical 
investigations, instituted with no method or with insuffj- 



ETIOLOGY. 49 

cient methods, or with good methods which will be im- 
proved upon to-morrow, are able to revolutionize, at one 
stroke, modern pathology. Progress is slow, no matter 
how rapid. 

There are schizomycetae, more or less, in most cases of 
diphtheria and other infectious diseases. But it is not 
proven, but only claimed that they are essential. Even 
when micrococci, by immense accumulation in certain local- 
ities, result in a local necrosis of the tissue, it may be 
claimed, but it is not proven at all, that this effect of the 
parasites is the essence of diphtheria. We know that in a 
certain period of relapsing fever the spirochete discovered 
by Obermeier is always met with, but we also know that 
the theory of the disease itself has not yet been materially 
advanced by the discovery, be it ever so interesting and, 
let us hope, important. There is, without any doubt, in 
every anthrax the bacterium anthracis Cohn. Still it is 
an undeniable fact that the blood from those sick with 
anthrax transferred to the healthy animal destroys life 
very rapidly, before a considerable development of bacte- 
ria can take place ; and also that the poisonous nature 
of the blood increases in virulence beyond any proportion 
to the increase of the parasites. That circumstance mili- 
tates rather for a chemical than a parasitic poison. 

Meanwhile, however, the parasitists have accomplished 
a victory. For the public mind and the judge's bench even 
is infected with bacteric faith. Bacteria are recognized by 
jurisprudence. The Berl. klin. Woch. of August 2d, 1880, 
refers to a forensic case, in which an unlicensed practitioner 
was found guilty of " having permitted, by his therapeuti- 
cal procedures, the bacteria to enter the body of a patient, 
and caused her death thereby." 

SUMMARY. 

Diphtheria is pre-eminently a disease of childhood. It 
is not frequent amongst adults, very rare in old age. 

It is not frequent in the first year. Still there are, for 
4 



50 A TREATISE ON DIPHTHERIA. 

physiological reasons, more cases before the third month 
than between the third and seventh or eighth. 

The sexes are liable to be taken in about equal propor- 
tion. Laryngeal diphtheria is more frequent in boys. 
Recoveries from it in girls. 

Diphtheria is apt to recur in those who once had it. 
Even membranous croup has been observed twice in the 
same patients. 

Some individuals, and even families, have a certain 
degree either of immunity or predisposition. 

Exposure and " colds " may act, but as proximate causes 
only. Most cases take place in the winter months in our 
climate, but there is no " invariable season law." 

" Filth " contributes to the generation of diphtheria, as 
it does to dysentery and typhoid fever. 

The question of a live origin of contagious disease in 
general was raised by Henle in 1840, also by Sir H. Hol- 
land, and Eisenmann. 

Some pathologists find the morbific source of diphtheria 
in bacteria. " No bacteria, no diphtheria." This is not 
truer than that fermentation or putrefaction depend on 
bacteria only. 

The presence of bacteria in the diphtheritic blood has 
not been proven. There is no theoretical ground for 
assuming that preventing the bacteria of a diphtheritic 
patch from making their way through the underlying 
mucous membrane will, /w se, prevent general diphtheri- 
tic infection of the system. On the contrary, the septic 
and putrid poison is claimed by A. Hiller- as distinctly 
chemical. Of the same nature, viz., chemical, is very proba- 
bly the poison of those of the infectious and contagious 
diseases in which the presence of a characteristic parasite 
is a recognized fact, as anthrax and relapsing fever. 



THE MANNER OF INFECTION. 5 I 



CHAPTER III. 
THE MANNER OF INFECTION. 

The view that diphtheria is a general infectious disease 
of the blood, rather than the result of a local infection, its 
upholders attempt to prove by a host of reasons which 
may be summed up as follows : 

Diphtheria occurs epidemically. This rule is not in 
collision with the fact that there are sporadic cases like- 
wise, for the same holds good for measles, scarlatina, and 
small-pox. The principal objection to it, however, lies in 
the fact that diphtheria has not a typical course, and that 
so far from one attack of the disease offering a security 
against its recurrence in the future, the disease has a ten- 
dency to revisit those who have undergone a previous at- 
tack. 

Epidemics of this disease, as of others, differ induration 
and severity. 

There is a period of incubation which, it is true, varies 
from two days to two weeks. 

Diphtheria is communicable by contagion and inocu- 
lation. Yet this can be said of every local contagious skin- 
disease, and the diphtheritic poison behaves in the same 
manner as the acarus scabiei. 

Constitutional symptoms, as pain in the limbs, lassitude, 
chilliness, fever, and convulsions may be present for hours 
and days before the appearance of the local symptoms ; 
and symptoms of general poisoning and adynamia are fre- 
quent. 

Albuminuria is a more frequent and earlier occurrence 
than the height of fever, if present at all, would explain. 



52 A TREATISE ON DIPHTHERIA. 

Furthermore, the frequent occurrence of paralysis as a 
sequela of the disease would speak for an attack upon the 
general system from the very outset. 

The study of the manner in which diphtheria effects an 
entry into the body, whether by a primary poisoning of 
the blood or by local infection, would perhaps afford the 
most ready solution of the entire question. But one case 
does not explain all, and diversity of opinion or observa- 
tions ever so correct, would only. prove the diversity of 
natural occurrences. So much is positive, that there are 
certainly some cases in which a local affection is the first 
symptom of the disease. Mercado's old case of diph- 
theria, engendered by the biting of a finger, has been 
alluded to in Chapter I. I know of one case in which the 
vagina became first affected and later the pharynx. Bayles 
saw denuded portions of skin assume a membranous char- 
acter, and general diphtheria develop afterwards. Fresh 
wounds become diphtheritic and the general disease arises 
from this source. Even paralysis will follow. I had a 
death from diphtheria when a long incision into a phleg- 
mon of the thigh had become diphtheritic. A little girl, 
who had a considerable amount of discharge from a 
catarrhal vagina, and sore thighs in consequence, ex- 
hibited first, during the prevailing epidemic of 1877, mem- 
branes on the denuded cutis, and afterwards general 
diphtheria. The boy, whose case I shall relate later as 
one of diphtheria of the pharynx, had general symptoms 
of diphtheria, fever, and pharyngeal affection. H. Brehm 
reports the case of a woman on whom he performed 
colotomy. The wound became thoroughly diphtheritic 
and gangrenous, but the pharynx and respiratory organs 
remained intact. A few days after, her daughter, who 
attended her in her sickness, was infected. In her, the 
pharynx was the seat of disorder. Besides, the tonsils 
are very frequently coated with a membrane without any 
general symptoms in the beginning, fever and general ill- 
ness occurring only later on. Now all of these facts 



THE MANNER OF INFECTION. 53 

tend to show that there are cases in which the origin of the 
disease is purely local. 

It must not be forgotten that during the prevalence 
of an epidemic every one is more or less under its influ- 
ence, and but little is wanting to call forth the disease. 
Some years ago, a well-known physician, with whom I 
was intimately acquainted, died from facial erysipelas 
and meningitis, which had originated in a slight abrasion 
of the upper lip. During an epidemic of typhoid we 
daily see persons with fever, headache, and lassitude 
Diarrheas are frequent during an epidemic of cholera. 
An epidemic of diphtheria is accompanied by a great 
number of cases of pharyngitis. When I, in the year 
i860 (Amer. Med. Times, Aug.), reported two hundred 
cases of bona fide diphtheria, I at the same time observed 
one hundred and eighty-five cases of non-membranous in- 
flammations of the throat. Therefore, contrary to the 
view of a local origin of diphtheria it may be claimed 
that the individual taking the disease was already satu- 
rated with the poison, and the local membrane repre- 
sented perhaps nothing but a symptom, or at the utmost 
the causa proximo.. Accordingly, then, there are un- 
doubtedly cases in which the pharyngeal membrane is the 
first cause and symptom of the final affection, and others 
in which the poisoning of the blood through inhala- 
tion is the first step in the development of the disease, 
amongst the s}^mptoms of which the pharyngeal mem- 
brane counts as one. 

The view that many cases of diphtheria are constitu- 
tional affections is supported by the fact that the first 
complaints of the patient relate to the general condition. 
The symptoms will be described later. Sometimes the 
patients are ignorant of any throat trouble when they 
consult a physician. On the other hand, it is true that 
the throat and respiratory passages in general are usu- 
ally and, in fact, almost exclusively the seat of the visible 
affection, and this would seem to indicate that the infec- 



54 A TREATISE ON DIPHTHERIA. 

tious elements while being inhaled are deposited on some 
of these parts, and are there developed and set in action ; 
in other words, favoring the view of a local action. This 
facilitates the possibility of simultaneous affections of both 
the throat and the blood in the lungs, in either equal 
or variable proportions. We are easily led to defend at 
least a partial admission of the poison by the respiratory 
act, when we reflect that the membranes which are swal- 
lowed are rendered innocuous by the action of the gastric 
fluids, and, therefore, the alimentary canal, from the oesoph- 
agus downwards, cannot be made responsible for the 
admission of the poison. Thus it is that the general symp- 
toms — as fever, lassitude, etc. — precede the local phenom- 
ena in very many cases ; while there are exceptional cases 
in which the membrane appeared first, and the fever 
later. This is especially the case when the tonsils are 
very large and occupy a prominent position in the throat. 
The difference in the invasion of diphtheria can be clearly 
illustrated by the following cases : Two boys, in a certain 
family, became sick at the same time ; one, whose ton- 
sils were small and barely visible, suffered from fever and 
headache, but the membrane could hardly be distin- 
guished. In the other, whose tonsils were large and very 
prominent, they exhibited an extensive membranous layer, 
but he was free from fever. On the second day, the for- 
mer of the boys had a distinct membrane on his tonsils ; 
the latter was feverish. Thus individual cases must be 
compared with reference to the elevation of temperature, 
the extent of the membrane, and the longer or shorter 
duration of the disease, and their significance and prob- 
able origin estimated. 

Those cases which begin with high fever and moderate 
or even no local symptoms must be looked upon as con- 
stitutional diseases, brought about in this wise : The vast 
ocean of blood in the lungs, with a surface of two thou- 
sand^square feet, which contains a fifth part of the entire 
mass of the blood, is separated from the vitiated atmo- 



THE MANNER OF INFECTION. 55 

spheric air only by the thin epithelial layer (which is even 
absent at times) of the alveoli of the lungs, by a delicate 
basement membrane and by a fine capillary network. In 
this connection it is immaterial whether diphtheria be 
ascribed to a parasitic or a chemical infection. The latter, 
when we remember the destructive effect the alkaline 
blood has on bacteria, would best explain, by a saturation 
of the blood, either direct or catalytic, the symptoms of . 
the disease. In cases accompanied by a high fever and 
a slight formation of membrane, no other explanation 
would be satisfactory. Of course, there may be various 
degrees of invasion. 

Should a person, in the course of several hours or a 
day, be taken with high fever and a moderate membrane 
formation, these symptoms subsiding in one or two days, 
leaving the patient weak and exhausted, but fully re- 
stored to health at the end of a week, we would be justi- 
fied in assuming — cceteris paribus — that there was a rapid 
absorption of a large amount of poison, and an equally 
rapid elimination thereof. Thus, my colleague, Dr. 
Conrad, found the temperature in the axilla of a patient 
to be 107 F., after eighteen hours, 102 , and in a few 
days, 99 . The same experience I have often had. They 
are, moreover, the same cases, in which the second or 
third day of the disease furnishes albuminuria, with rapid 
elimination and speedy recovery. When, however, the 
process is slow in developing, accompanied by moderate 
fever, and the course is indolent, we have reason to infer 
that moderate amounts of the poison are being continu- 
ally taken into the system, and making their influence felt 
to a moderate degree, but for a longer period. Such are 
the cases which, without any violent symptoms, are ac- 
companied by frequent local relapses, or run, when the 
absorption is constant as well as copious, a septic course, 
or terminate in paralysis. 

These are my views on the question of a general or a 
local cause of diphtheria. There are cases in which a 



56 A TREATISE ON DIPHTHERIA. 

local infection of the skin, or of a wound, may be one of 
the causes, or the only cause, of the disease, and there are 
cases in which the poison, in passing through the pharynx, 
gives rise to local phenomena before the system at large 
gives evidence of infection. But as a general thing diph- 
theria must be looked upon as a constitutional disease, 
giving rise to local phenomena, in the same way as scar- 
latina does on the skin, on the mucous membrane of the 
alimentary canal, and in the uriniferous tubules ; measles 
on the skin and respiratory mucous membrane, or typhoid 
in the lymph follicles and on the mucous membrane of the 
intestine ; or in other words, the diphtheritic poison may 
enter the system locally through a sore or wounded integ- 
ument, or through the lungs. 

SUMMARY. 

The entrance of the diphtheritic poison into the system 
is not the same in all cases. 

There are cases in which the origin of the disease is 
decidedly local. 

There are others in which the poisoning of the blood 
through inhalation is the first step in the development of 
the disease. 

In many cases, both a sore integument and the lungs 
are the inlets of the poison simultaneously. 

It is probable that the configuration of the vestibules 
of the respiratory apparatus, and the amount of active 
poison, and the duration of the exposure to it, modify the 
intensity of the symptoms and the course of the disease. 



CONTAGION AND INCUBATION. 57 



CHAPTER IV. 
CONTAGION AND INCUBATION. 

That the contagiousness of diphtheria should still be 
doubted is hardly possible, and still the public act as if it 
did not exist. One of the latest facts is that communicated 
by Trammer to the annual meeting of the Illinois State 
Medical Society, on May 18th, 1880 (Med. Rec., June 
1 2th). In one school district, with 59 pupils, an epidemic 
was started (no cases having previously existed) by two 
boys who visited a neighboring community where there 
were cases of the disease. »In a few days, both boys had 
symptoms of cold, received some domestic treatment for 
their little fever and sore throat, and soon returned to 
school, where other pupils complained of the offensive 
odor of their breath. Soon other cases appeared, and the 
number of persons attacked was 58, with 17 deaths." 

That diphtheria is contagious is beyond doubt.f The 
contagious element is directly communicated by the pa- 
tient ; it clings to solid and semi-solid bodies, and in this 
way is transmitted even after a long time. There is hardly 
any disease which can cling as tenaciously to dwellings 
and furniture ; it can be transported by the air, though 
probably not to a great distance, and hence in houses 
artificially heated, while the windows and doors are 



* There were 17 cases of nasal diphtheria, with 15 deaths. The treatment 
is reported as consisting of injections of a 3 to 4 per cent carbolic acid solution, 
and salicylic acid, tannin locally, and bromine, according to Wm. H. Thompson. 

f Though there be a man in Vienna who not only treats diphtheria as non- 
contagious in placing diphtheria patients into general hospital wards, but also 
writes pamphlets in that sense — or nonsense. 



58 A TREATISE ON DIPHTHERIA. 

mostly closed, rises from the lower to the upper stories, 
and it is for this reason advisable to keep the sick on the 
top floor. It is certainly transmitted by spoons, glasses, 
handkerchiefs, and towels used by the patient. The 
contagious character increases directly in proportion 
to the neglect of proper ventilation. A. Carpenter (Brit. 
Med. Jour., Jan. 4th, 1879), looks for a predisposing ele- 
ment in the development of diphtheria even in the accu- 
mulation, in dwellings and school-rooms, of carbonic acid 
gas. Fresh air, plain diet, sulphurous acid, and creasote 
are therefore the preventives. Workmen in gas factories, 
according to him, do not suffer from diphtheria. That it 
is spread by the feces is not clearly established in my 
mind. I can give personally no examples of its being 
spread by visitors or by the attending physician ; this is 
said to have occurred, however. The character of the 
disease communicated, and the local manifestation, do not 
depend on that of the original sufferer ; thus mild cases 
may produce severe ones, and vice versa ; and conva- 
lescents can convey the disease in its full force. Naturally 
the softer character of the tissues in children renders 
them more susceptible to infection, and the activity of 
their lymphatic system liable to severe forms of the 
disease. 

Many tragic cases are recorded in literature, of infec- 
tion by direct contact from pharynx to pharynx, or from 
the opening in the trachea to the mouth of the surgeon, 
and one of the saddest cases, perhaps, is that of the much 
lamented Carl Otto Weber. I became affected with 
diphtheritic pharyngitis followed by a tedious catarrh, 
consequent upon sucking the wound, during the perform- 
ance of tracheotomy, in an eight-year-old child, who died 
thirteen days later of gangrene of the trachea and anterior 
portion of the neck, and general septic poisoning. The in- 
fection in my case resulted in the outbreak two days after 
sucking out the wound. Oertel has seen diphtheria of the 
pharynx which was communicated by the act of kissing, 



CONTAGION AND INCUBATION. 59 

and developed in two days. A series of cases in which 
the surgeon was infected by membranes expelled during 
the performance of tracheotomy, and where the period of 
incubation was from two to three days, have been reported, 
particularly by French physicians. Dr. Symington, 
House Physician at Bellevue Hospital, New York, suffered 
in 1876 from a diphtheria of the pharynx followed by par- 
alysis of the soft palate and of the extremities, which lasted 
for months, after exposing himself to direct infection from 
a tracheotomized windpipe. In his case, too, a period of 
two days elapsed between infection and the appearance 
of the disease. 

In regard to the length of the incubation periods, there 
can be no better authenticated facts than those contained 
in a report of Dr. Elisha Harris to the National Board of 
Health, an abstract of which is found in No. 1, National 
Board of Health Bulletin, June 28th, 1879. The report 
says that, in the fourth school district of the township of 
Newark (Northern Vermont), amidst the steep hills, where 
reside a quiet people in comfortable dwellings, the sum- 
mer term of school opened on the 12th of May. Among 
the twenty-two little children who assembled in the 
school-room in the glen were two who had suffered from a 
mild attack of diphtheria in April, and one of them was, 
at the time school opened, suffering badly from what ap- 
peared to have been a relapse in the form of diphtheritic 
ophthalmia. Besides, it is proved that these recently sick 
pupils had not been well cleansed, one of them having on 
an unwashed garment that she had worn in all her sick- 
ness three weeks previously. 

At the end of the third day of school, several of the chil 
drenwere complaining of sore throat, headache, and dizzi- 
ness, and on the fourth day and evening so many were 
sick in the same way that the teacher and officers an- 
nounced the school temporarily closed. By the end of 
the sixth day from school opening, sixteen of the twenty- 
two previously healthy children became seriously sick 



60 A TREATISE ON DIPHTHERIA. 

with symptoms of malignant diphtheria, and some were 
already dying-. The teacher and six of the pupils were 
not attacked, nor have they since suffered from the disease. 

The Wiirt. Med. Corresp. BL, 1878, No. 2, reports the 
case of a surgeon who, while attending a diphtheritic 
child, had some secretion thrown into his face. Twelve 
hours after, his right eye was inflamed and painful. After 
thirty-six hours, the conjunctiva bulbi exhibited a diffuse 
redness, and secreted a turbid fluid mixed with shreds. 
The cornea was disfigured by several ulcerations. Pho- 
tophobia and much headache. Eserine 1 : 100 was used 
six to eight times daily ; thirty-six hours after, while the 
right eye was improving, the left was affected similarly 
but less seriously. The same treatment was continued, 
and recovery took place after some weeks, nothing re- 
maining of the affection except a few yellowish spots and 
some photophobia. 

It would then appear that, in the direct communication 
of the disease to healthy or nearly healthy mucous mem- 
branes — as healthy as the prevailing epidemic will allow — 
the period of incubation is two days. In only a small num- 
ber of cases, the disease has an apparently shorter period 
of incubation than this ; as when tonsillotomy or a similar 
operation is undertaken during the prevalence of an epi- 
demic. One may rest assured that any operation on the 
tonsils, while an epidemic of diphtheria is at its height, 
will be followed in twenty-four hours by diphtheritic de- 
posits on the operated part. To what extent we are 
justified in considering this a bona-ftde incubation of the 
disease in a previously healthy body is, of course, another 
question. It seems to me that these cases positively 
prove that the operation is only the causa proxima of a 
diphtheritic affection, and that we have rightly taken it 
for granted that during an epidemic every individual is 
more or less under its influence and affected by it, so that 
it needs but a wound or an accidental abrasion of the sur- 
face of the mucous membrane to call the disease into 



CONTAGION AND INCUBATION. 6 1 

action. In a similar way fresh wounds, or morbid condi- 
tions of the mouth, may call forth the disease. The 
ruptured vesicles of a follicular stomatitis are liable to 
serve as resting places for diphtheritic membranes, 
and thus I have seen the complication of a follicular 
stomatitis with oral diphtheria ; and any lacerations of 
the vagina during labor may become diphtheritic within 
twenty-four hours. If now, on the one hand, incubation 
depends on the condition of the affected surface, it is prob- 
able, on the other hand, that the intensity of the poison 
at the time, plays an important part in determining the 
period that is to elapse between infection and the invasion 
of the disease. It is so very difficult to fix the period of 
incubation in every case — that it should differ in different 
cases is certain — for the reason that in many the objective 
symptoms of diphtheria are very unimportant, and the 
physician's attention is only called to them after a number 
of days. Moreover, the nature of the infection is still lit- 
tle understood, and the question of a local or a general 
beginning of many individual cases of the disease still re- 
mains a mooted point. The fact that a number of constitu- 
tional symptoms may precede the outbreak of the local 
infection would at once indicate that a certain class of 
cases is most assuredly dependent on a general infection, and 
cannot be traced to a local influence. If this be true, it be- 
comes a difficult matter to determine the period of incu- 
bation. During an epidemic there are many possible 
modes of infection, and diphtheria in so far resembles 
other infectious diseases that it does not require a real 
bodily contact to take or give the disease. After all that 
has been said, it can be easily understood that, while in a 
certain class of cases the period of incubation will be one 
or two days, in another class ten or twelve days will have 
elapsed ere this stage is completed. 

In regard to the outbreak of first, or apparently first, 
cases in an epidemic, air polluted by bad drainage, or 
leaky sewers, have been accused in diphtheria as well as 



62 A TREATISE ON DIPHTHERIA. 

in typhoid fever and in dysentery. Not only the impair- 
ment of general health, but the direct and unmistakable 
disease has been attributed to it. Thus Bayley refers, in 
the endemic of Bromley (Sanit. Record, Aug. ioth, 1877), 
the first cases to unventilated sewers and cesspools. 
School-children multiplied the disease. Thursfield at- 
tributes the diphtheria at Ellesmere (San. Rec, 158, 1877) 
to the accumulation of excrements under the schoolroom, 
and to deficient supply of water, which moreover was of 
bad quality. Tripe (like Railton, Bailey, Russel, Bell) 
accuses sewer gas (San. Rec, June 14th, 1878) ; others, 
polluted waters or bad drainage (April 18th, May 2d, 

1879). 

In regard to polluted water, I do not think that path- 
ologists who attribute infectious diseases to bacteria only, 
are justified in condemning it. It may not be so guilty 
after 'all. For the admixtures, anorganic and organic, 
minerals, admixtures of wood and plants, also lower fungi 
and their products — algae, infusoria — would render water 
rather disagreeable, but not exactly unhealthy. The latter 
effect can be accomplished — always assuming the bac- 
teria theory correct, for the sake of argument — by bac- 
teria only. But when they arrive in the stomach, their 
doom is sealed, they are decomposed. The only places 
where possibly they could take root would be diseased 
or ulcerated places in either the oral cavity or the upper 
portion of the oesophagus. Filtering would be of no use, 
if it were advised for hygienic purposes, for bacteria pass 
any filter except clay. The plea of taste or appearance 
alone is not sustained before the bacteria forum, the prob- 
lem of diphtheria is not an aesthetical question* at all. 

* The principles and the method of the microscopical examination of water 
have been discussed by L. Hirt, in Zeitsch. f. Biol., 1879, Vol. 15 He dis- 
tinguishes and treats separately of three varieties and classes of water ; 1st, 
pure water ; 2d, suspicious ; 3d, putrid water, not fit to drink. 

No. 1 contains no organisms even after three or five days ; a few algae or 
diatomacese are permissible. They live on anorganic material only and do not 
change the character of the water. Some bacteria are almost always found. 



CONTAGION AND INCUBATION. 63 

Not only water, but milk also has been found guilty 
of giving - rise to diphtheria endemics. According to 
W. B. Power, * we already know of certain diseases 
in the cow capable of affecting the human subject with 
disease. A. There is vaccinia, a disease of which we know 
that it belongs to the same class with small-pox. B. " Foot 
and mouth disease," which in its various stages affects the 
milk secretion to a varying degree, and is transferable, 
though not readily, with the milk, giving rise to aphthous 
affections and disturbances of the -stomach and bowels. C. 
Miliary tubercle of the cow, which can give tubercle to ani- 
mals (perhaps including man ?) that consume milk of the 
affected cow. D. There is an anthrax fever of oxen and 
cows, which has been convicted of causing malignant car- 
buncular disease among people who have eaten the flesh, 
and a throat disease very much like diphtheria among pigs 
that have been fed on it and on the milk. 

No. 2 contains saprophyta (sphagrotilus natans, leptothrix, anthophysa 
Mulleri) which live on the products of putrefaction, and larger infusoria. Also 
hair, wool, wood, as accidental admixtures. 

No. 3, large masses of bacteria, saprophyta, and infusoria. A turbid 
appearance of water does not prove the presence of organic impurities ; they 
may be anorganic, iron, etc. Moderate quantities of all of the above para- 
sites are of no account, however. But the most dangerous inhabitants of 
water are large numbers of flagellata, which live on dissolved organic material 
and may be looked upon as the main putrefaction infusoria (monas, chilo- 
monas, peranema, englema). 

Dr. Langfeldt (D. Viertelj. f. off. Ges., XII., 1880, p. 522) experimented 
in regard to drinking water containing microscopical animals, which are not 
destroyed by tea, coffee, Selters water, effervescent draughts, or a mild admix- 
ture of alcoholic beverages. He observed nais proboscidea, anguillula fluvi- 
atilis, euplotes charon, oxytricha gibba, zoothamnium nutans, colpoda cucul- 
lus, volvox globator, loxophyllum lamella. The addition of one-twentieth per 
cent of citric acid destroyed all of these within two minutes. When dead they 
sink to the bottom of the vessels within a minute, and can be avoided in 
drinking. It is desirable to dissolve the acid each time before using, as a so- 
lution is liable to spoil when preserved. Only such as are protected by a 
harder skeleton — cyclops quadricornis — or a thick epidermis were not affected 
by the citric acid solution. 

* Thoughts on the Nature of certain observed Relations between Diphtheria 
and Milk. Trans. Path. Soc, London, XXX., 1879, p. 546. Brit. Med. 
Journ., Jan. nth, 1879. Practit., 1879, XXII., p. 306. 



64 A TREATISE ON DIPHTHERIA. 

Mr. Powers concludes that, therefore, though a connec- 
tion between diphtheria and the consumption of milk have 
not been proven as yet, still it is very probable indeed. 
His careful investigations into the causes of some local epi- 
demics in North London exclude any other source from 
which the people could have been affected. Perhaps one 
of the forms of " garget," cow mammitis, is of an infectious 
character. 

His reasoning, however, is not accepted by A. Dowrus,* 
who still believes that the milk, which gave rise to diph- 
theria at a distance, may have been soiled and infected. For 
though the connection between milk and scarlatina and 
typhoid fever be known for years and variously studied, no 
observation of the kind had yet been made in regard to 
diphtheria. Besides, where the young, in England, drink 
much milk, viz., in the cities, diphtheria was very much less 
frequent than where little or no milk was taken, viz., in the 
country. Even in the country, the well-to-do classes, who 
drink milk, had but little diphtheria, while the children of 
the poor, who obtained none, suffered a great deal from it. 

In regard to this transmission of diphtheria by means of 
milk, O. Bollinger f hesitates to express any opinion ex- 
cept that the matter is very doubtful indeed. For the mode 
of the infection of the milk is certainly obscure, perhaps 
more so than the connection of typhoid fever with milk. 
" Garget " being a name for different conditions of the ud- 
der, a differential diagnosis will be required in order to 
determine which form of garget is so diphtheritic as to 
transfer diphtheria. This latter disease, however, does 
not appear to be very uncommon amongst the bovine race, 
provided the epidemic malignant catarrhal fever is of that 
nature. It is mainly found in the nares, mouth, and 
larynx. 

Probably the possibility of contracting diphtheria di- 
rectly from animals is very much greater than the danger 

* Diphtheria and Milk Supply. Brit. Med. Journ., Feb. 1st, 1879. 
f D. Z. f. Thiermed. u. vergleich. Pathol., VI., 1879, p. 7. 



CONTAGION AND INCUBATION. 65 

from water or milk. If that be so, many obscure cases, 
endemic or epidemic, will admit of a readier explanation 
than at present. 

On a Pomeranian farm, during the winter 1875-6, every 
newly-born calf died of a disease with the following symp- 
toms : More or less abundant salivation, yellow or green- 
ish discharge from the nostrils, swelling of the cheeks, 
cough, and sometimes diarrhea. Extensive ulcerations of 
the cheeks, tongue, palate, nasal fossae, larynx, bronchi, and 
intestines ; ulcerations about the feet, caseous deposits in 
the lungs, with a beginning of pleurisy. In the liver, 
spleen and kidneys, nothing abnormal. The ulcerations 
presented the character of diphtheritic ulcerations : plenty 
of micrococci on the surface, inside a network of fibrin- 
ous filaments, inclosing round cells, micrococci, and detri- 
tus of mucous membrane. A healthy calf was affected the 
same way after having been brought in contact with the 
diseased ones. New-born lambs were infected by inocula- 
tion. Not so grown-up cows and bulls. But the superin- 
tendent of the farm and the woman who attended the 
calves were taken with diphtheritic angina.* A number of 
similar observations were made by F. Blazekovic.f He, 
moreover, like Damman, unlike Bugnion J counts the 
epidemic catarrhal fever of the bovine race amongst 
diphtheritic affections. Observations of his own prove 
contagiousness, mainly of the newly-born calves, the 
effectiveness of isolation, and infection of the lungs. 
Congestion of the bronchial mucous membrane and local 
pulmonary congestion he also found in calves that still 
were in apparently good health. It is not evident from 
his remarks whether he believes in a local or constitutional 
origin of the disease. The incubation lasted five days or 
less. 

In a short paper on mycotic diseases in birds, O. Bollinger 
reports a mycosis of the trachea and lungs. The bird, a par- 

* Damman : D. Zeitsch. f. Thiermed., 1876, p. 1. 

f The same, 1878, p. 64. % Same Jour., p. 87. 

5 



66 A TREATISE ON DIPHTHERIA. 

rot, died of croup of the trachea, the obstruction resulting 
from a clot consisting- of accumulations of aspergillus glau- 
cus, fibrin, and corpuscles. Another case revealed a similar 
affection of the bronchi with aspergillus nigrescens, and a 
mycotic, ulcerous endocarditis of the valves of the left 
heart in a hen. The endocarditic deposits consisted of 
zooglcea, coagulated fibrin, and a certain number of red 
and white blood-cells. There was besides, oedema of the 
lungs, tumefaction and fatty degeneration of liver, with 
yellowish infarctus in one lobe, spleen of double size, kid- 
neys enlarged, hemorrhagic enteritis, universal anasmia, 
numerous micrococci in liver, spleen and kidneys, and in 
the blood. In the same yard, fifty fowl had died within a 
short time.* 

Friedberger's report presented to the Veterinary Society 
of Munich, f on croup and diphtheria of domestic fowl 
leaves no doubt as to its frequency, particularly amongst 
the nobler varieties. The mouth, throat, and larynx (with 
croup symptoms), nares (serous, purulent, fetid discharge), 
cella infraocularis (which takes the place of antrum High- 
mori), conjunctiva, cornea, sclera, upper portion of intes- 
tinal tract (catarrh), are affected as they are in the human 
patient, perhaps with a greater liability to destruction of 
the eye — while the fever, also like what we see in the hu- 
man patient, does not always appear to be high. Leu- 
cocytes in large numbers, detritus at an early period, 
pavement epithelium in small numbers, many bacteria, 
micrococci, and bacilli, also fungi of a high order, but little 
fibrin, were usually found. But there were many specimes 
of deposits taken from the cavities (cella infraocularis, etc.), 
where no bacteria were found. The course of the disease is 
slow, generally extending over several months, the mor- 
tality great mainly amongst the finer varieties of pigeons 

*Z. f. Thiermed., 1878, 253. 

fD. Z. f. Thiermed., V., 1879. P- I ^i. Friedberger refers to Dupart 1868, 
Peroncito 1870, Unterber^er 1872, Siedamgrotzky 1872, Buhl 1877, Saur 1875, 
Reul 1874, Wortley 1877, Konhauser 1878, Greuter 1878. 



CONTAGION AND INCUBATION. 67 

and hens ; it amounts to eighty per cent, and the treatment 
is very unreliable. 

Nicati * studied an epidemic diphtheria amongst hens, 
which had similar symptoms and a course very much like 
that in man; it could be inoculated into other animals, and 
was cotemporaneous with the outbreak of the epidemic 
amongst the human population of Marseilles. Trasbotf 
succeeded in inoculating a healthy hen from a diphthe- 
ritic one, but the attempts at transmission to dog, pig, 
and man were unsuccessful. The Med. and Surg. Jour- 
nal (Med. Rec, Nov. 8th, 1879) contains the following: 
In a house at Ogdensburgh, N. Y., five children were ill 
with diphtheria. Three kittens who had been playing 
with them from time to time, took the disease and died. 
Post-mortem examinatio.n showed diphtheritic membranes 
in their throats. 

SUMMARY. 

Diphtheria is very contagious. Both the patient and 
his surroundings, dwelling, furniture, towels, etc., convey 
the disease. In dwellings it rises to the upper stories with 
the current of warm air. The poison clings mostly to 
mucous membranes. Mild cases may communicate seri- 
ous ones and vice versa. The period of incubation lasts 
two days or more. It may last a fortnight. Fresh wounds 
do not require so long to be affected. In these cases the 
supposition is, that the patient was already influenced by 
the epidemic. Visible symptoms of diphtheria are often 
noticed after the constitutional ones. 

* Revue d'Hygiene et de Police Sanitaire, 1879, p. 3. 

f De la transmission de la diphth. des animaux a 1'homme. Gaz. hebdom., 
1879, avril 25. 



68 A TREATISE ON DIPHTHERIA. 



CHAPTER V. 
SYMPTOMS. 

PHARYNX AND SOFT PALATE. 

In the majority of cases, the disease has a prodromal 
stage of longer or shorter duration ; usually it lasts a 
day or two, and may run a similar course to that of a 
catarrhal phalangitis. The patient feels somewhat in- 
disposed, has slight fever, is dejected, complains of 
painful deglutition, more marked. when swallowing fluids 
than solids or semi-solids, has headache and, occasion- 
ally, vomiting. The occurrence of the latter, however, 
is very much less frequent than in the outbreak of scarla- 
tina. In very severe cases, convulsions have been observed; 
chills very rarely; elevations of temperature of from 102. 5 
to 104 F. are frequent; higher ones, from io5°to 107 , sel- 
dom occur. At this time it is often difficult or impossible to 
distinguish a catarrhal angina from a diphtheritic, by the 
subjective symptoms. Slight glandular swellings under 
the jaw may occur in either. The characteristic objective 
symptom of the latter disease is the presence of membrane 
on the reddened mucous membrane of the fauces, which 
is markedly injected over all or part of the surface. The 
arches of the palate and the tonsils, less frequently the poste- 
rior wall of the pharynx are so affected. A distinctly local- 
ized redness cannot be but either traumatic or diphtheritic. 
Larger or smaller deposits are found thereon, lying loose 
on the surface or deeply imbedded according to the locality. 
At times the first examination reveals their presence in 
large numbers, at other times but a single one can be de- 
tected, which is soon followed by others, however. Within 
a certain period of time, as a rule twelve to twenty-four 



SYMPTOMS. 69 

hours, the single deposits coalesce and form a membrane of 
greater or less extent. Mostly in the same proportion to its 
increase in size, it increases in thickness, partly by an actual 
homogeneous growth, partly by the addition of blood, 
mucus, or other foreign substances. On the uvula, soft 
palate, and the posterior wall of the pharynx, the membrane 
is located superficially and at times can be easily removed; 
on the tonsils, it has a firmer hold and is occasionally amal- 
gamated with the uppermost tissues thereof. On the other 
hand, there are cases in which no actual membranous for- 
mation occurs ; in such cases the tissues are more or less 
swollen, the surrounding portions more or less reddened, 
and the grayish-white discoloration is the result of an in- 
filtration of the tissues themselves, and cannot be removed, 
as was possible in the cases previously spoken of.* 

There are still other cases, in which deposits of mem- 
brane and tissue infiltration are found at the same time, 
and where both history and evidence indicate that these 
two phenomena are the result of one and the same process. 
When the uvula takes part in the process, the swelling is, 
as a rule, more marked than when the remaining parts of 
the fauces only are implicated. Its circumference is very 
considerable and amounts sometimes to the treble or quad- 
ruple of the normal, in consequence of the cedematous con- 
dition of the entire tissue. 

We have to deal, then, with three different manifesta- 

* The diagnostic differences between primary pharyngeal diphtheria and 
scarlatinous diphtheria, such as O. Heubner describes them (Jahrb. f. Kinder- 
heilkunde, XIV., p. 1), are in my opinion very much overdrawn. According 
to him, they differ both clinically and anatomically. In scarlatina the depos- 
its are always thin (?), no membranes are thrown off (?), and it is impossible to 
remove them by artificial means (?). In pharyngeal diphtheria there is no epi- 
thelium imbedded in the membranes (?), in scarlatinous diphtheria it was so 
found several times, though in a changed condition. The latter gave rise to 
actual necrosis of the tissue, and in several cases to general pharyngeal gan- 
grene. Very few of my readers will admit that the views of the writer corre- 
spond with their own experience to such an extent as to induce them to oblite- 
rate in their minds the various transitions between the extreme forms above 
depicted and to admit their essential difference. 



•JO A TREATISE ON DIPHTHERIA. 

tions of the diphtheritic process : first, with a membrane 
lying on the mucous membrane, and removable without 
causing much injury to the epithelium, or any to the base- 
ment membrane ; such membranes were given by some the name 
of croupous deposits ; secondly, with a membrane implicating 
the epithelium and upper layers of the mucous membrane; 
to this, the title of diphtheritic membrane has been given, by 
preference; thirdly, with a whitish or grayish infiltration 
of the surface and the deeper tissue, which, if abundant, 
may give rise to a necrotic destruction of the tissue. 

The severity of the disease does not always depend on the 
predominance of one of these three forms, for any of them 
may accompany a mild or a severe attack. By a severe at- 
tack we understand one attended with chills, temperatures 
as high as 105 and 107 F., and marked nervous symp- 
toms, such as vomiting and convulsions. It is characteris- 
tic of such cases that, when the membrane is accidentally 
or forcibly removed, it is speedily reproduced ; the lymph- 
atic system, in addition, takes an active part in the pro- 
cess. The neighboring glands become swollen, the peri- 
glandular tissue does likewise, so that the circumference 
of the neck becomes enormous, and the space between the 
lower jaw and the clavicle appears one immense tumefac- 
tion. These are the cases in which, as a rule, loss of 
strength and general debility speedily ensue, and death 
occurs from exhaustion. The membrane, in cases of this 
description, frequently undergoes changes in appearance; 
under the influence of the atmosphere and of foreign 
substances, and by admixture of blood, its color becomes 
yellowish or brownish. The odor of the membrane and 
surrounding parts becomes sweetish and musty, and occa- 
sionally so fetid that it contaminates the atmosphere of the 
room, and the air in its transit through the nose and over the 
pharynx becomes by inhalation still more infectious and 
dangerous to the patient. His throat becomes more swol- 
len, his respiration loud, he keeps his mouth open con- 
stantly, has an indifferent expression, the saliva dribbles 



SYMPTOMS. /I 

continually, the color of the skin is sallow and livid, the 
appetite very poor, and pulse both frequent and small. 
When the symptoms are of long duration, and a deep 
infiltration of the affected parts occurs, hemorrhages 
not infrequently make their appearance. These may be 
slight although frequent ; occasionally, however, larger 
blood-vessels are encroached upon in the process of 
destruction, and dangerous, nay even fatal hemorrhages 
may be the result. The septic forms which I have here 
described are more dangerous than the mild ones, previ- 
ously mentioned. Still, even in the latter, bad results may 
ensue from a direct absorption into the blood of putrid 
substances, and by the penetration of fetid gases to the 
lungs. 

Occasionally, where the infiltration has been extensive, 
we meet with a condition that can only be considered as 
gangrene. In such cases we see collections of a grayish 
pulpy mass which, on falling off, leaves a considerable 
loss of tissue; the further course of the disease being either 
favorable, or dangerous through absorption of septic ma- 
terial, or accompanied by local hemorrhages. When 
after a time the health is completely restored, marked cica- 
trices are left behind. Such loss of tissue is generally seen 
in the tonsils only, but it may also be encountered in the 
soft palate. Its cicatrices on the soft palate are always a 
source of inconvenience, partly in swallowing, partly in 
speaking. Actual local perforation of the soft palate I 
have seen but four times in more than twenty years, 
sloughing without perforation, very often. 

NASAL CAVITIES. 

The diphtheritic membrane not infrequently spreads 
from the pharynx to the neighboring organs. From the 
posterior aspect of the soft palate or pharynx, the disease 
gradually ascends to the nasal cavities ; this is particularly 
apt to occur when the uvula is the seat of extensive de- 
posits, and by forced inspiration and deglutition its poste- 



72 A TREATISE ON DIPHTHERIA. 

rior surface becomes affected. In such cases, the mem- 
brane which extends thence to the nasal cavities is very 
dense, and capable of narrowing the capacity of the nasal 
cavities anteriorly, and occasionally even to close them 
entirely ; as a rule, however, several days elapse before 
the membrane assumes such a condition. Usually, when 
this form of nasal diphtheria is in its incipient stage, it is 
impossible to diagnosticate it ; the most important sign 
thereof, beside a more nasal articulation, and sometimes 
greater difficulty in deglutition, and the result of close 
ocular examination while the uvula is turned sideways or 
drawn forward, is a swelling of the deep facial glands at the 
angle of the lower jaw ; when these swell rapidly, it can be 
asserted positively that the nasal cavities have been in- 
vaded. Frequently there is little or no discharge from the 
nostrils under these circumstances. 

The picture is a very different one, however, when the 
nose becomes primarily affected. This usually occurs 
only where an acute catarrh with but little secretion, 
rarely where a chronic catarrh has immediately preceded 
infection. When the secretion was thin and serous, the 
diphtheritic infection renders it no thicker, but makes it 
slightly flocculent, and it may become very profuse. This 
form is frequently attended with a disagreeable odor, 
equally unpleasant to the patient and to those around him. 
During the prevalence of an epidemic, one must always be 
prepared to see an acute nasal catarrh, or an influenza, or 
even a chronic nasal catarrh become complicated with 
diphtheria or pass into it. Schuller reports the case of a 
five-week-old male child who, having had a nasal catarrh 
since birth, became affected with diphtheria of the nose. 
The glandular swelling of which I spoke above is a 
very important diagnostic, and likewise a decidedly un- 
pleasant, symptom which becomes very marked inside of 
twenty-four hours ; frequently a partial swelling remains 
long after the disappearance of the diphtheritic membrane. 
Such glands rarely suppurate or undergo a necrotic degen- 



SYMPTOMS. 73 

eration ; a permanent induration thereof, however, not in- 
frequently occurs. 

A chronic catarrh of the pharynx (and larynx), also the 
nose, is apt to remain after a serious attack of diphtheria. 
In that respect the latter does not differ much in character, 
though sometimes in degree, from attacks of non-infectious 
inflammations ; they also are the starting-points for a num- 
ber of subacute relapses or for chronic ailment. (Edema- 
tous swelling of the mucous membrane and submucous 
tissue is often observed for a long period to come ; elongated 
uvulae, enlarged tonsils, often date back to such an acute 
attack. Thus it is with the upper portion of the larynx 
about the posterior insertion of the vocal cords (see be- 
low) ; its large amount of loose submucous tissue is liable to 
swell considerably in acute attacks. Frequent spells of 
croupy cough, and a certain degree of dyspnoea is often ob- 
served for years afterwards. Though the cases of genuine 
cicatrization between the arytenoid cartilages, as described 
by Michael (Deutsch. Arch. f. klin. Med., 1879, XXIV., p. 
618), be rare, with their result of permanent paresis of 
the thyro-arytenoid interni muscles, still the cases are 
very obstinate. 

EYE. 

From the nose, the diphtheritic process frequently ex- 
tends to the nasal duct and from thence to the conjunctiva 
of the eye, although it is not claimed that diphtheritic 
conjunctivitis originates in this way only. In the early 
history, especially of the epidemic that has prevailed for 
the past twenty-two years, I frequently saw diphtheritic 
conjunctivitis either as a complication of diphtheria of the 
fauces or nose, or occurring primarily. Diphtheritic con 
junctivitis is an exceedingly dangerous disease as far as 
the safety of the affected eye is concerned ; not infre- 
quently the cornea is destroyed within twenty-four hours 
by gangrene from pressure, or by diphtheritic keratitis. 
Diphtheria of the conjunctiva is not, fortunately, a very 



74 A TREATISE ON DIPHTHERIA. 

common affection. It appears to be more frequent in 
some epidemics than in others. At all events, I have seen 
many more cases, compared with the whole number, in 
the first four or five years of the prevailing epidemic than 
in the last seventeen or eighteen. Its symptomatology 
and pathology were first studied by A. von Graefe, in 1854, 
but have since been the subject of frequent and careful ob- 
servation. The upper (sometimes the lower) eyelid is 
first taken, becomes suddenly red and rigid, and is greatly 
swollen. But rarely a single eyelid is the only seat of the 
affection during the whole course. At first the conjunc- 
tiva palpebrarum is smooth, dry, and pale, while that of 
the eye is chemosed, afterwards diphtheritic membrane is 
deposited in floccules or solid masses. After a few days 
the deposit begins to macerate and the eyelid is less 
hard. Deposits on the conjunctiva bulbi are less hard, 
and peel off more easily. At an early period, that is, often 
within twenty-four hours, the cornea becomes hazy and 
ulcerated. Perforation is very apt to take place, and 
either prolapse of the iris, or destruction of the eye, at all 
events loss of sight, are of frequent occurrence. 

EAR. 

In the same manner as the eye, the ear may become af- 
fected by continuity with the naso-pharyngeal space. The 
orifices of the Eustachian tubes in children are narrower 
than in adults, and present a slit-like aperture ; hence a 
slight swelling of the mucous membrane or a moderate 
diphtheritic deposit may close them, and hardness of hear- 
ing be the result. In these cases, the patient not infre- 
quently complains of intense pain behind the angle of the 
jaw and in the ear. In some cases, the diphtheritic mem- 
brane is continued into the tubes, giving rise to otitis 
interna and media, and finally terminating in a perforation 
of the drum-membrane, and occasionally in caries of the 
bones of the ear. 

Moos describes a case of diphtheria of the external audi- 



SYMPTOMS. 75 

tory canal in a boy of ten years, who had frequently suffered 
from a purulent discharge from the middle ear. He ob- 
served a profuse exudation holding fast for a number of days 
and accompanied during detachment by pain and hemor- 
rhage ; no complication existed in the throat or elsewhere. 
P. A. Callan (Med. Rec, 1875, p. 221) reports a similar case. 
Gruber asserts that diphtheria of the external auditory 
meatus occurs only when it has for some time previously 
been the seat of a catarrh. I recollect but one such case 
in my own practice, and but one primary case in which no 
catarrh preceded the diphtheritic membrane. Bezold, 
however, publishes (Virch. Arch., 70, p. 329) three ob- 
servations of fibrinous exudation on the drum-membrane 
and in the external ear. Wreder (Montassch. f. Ohr., No. 
10, 1868) collected eighteen cases of diphtheria of the 
middle ear in scarlatina, complicated with the same affec- 
tion of the fauces and nares ; one child with diphtheria of 
the mouth and pharynx had also diphtheria of the inner 
ear. Kupper saw diphtheria of the cavum tympani and 
Eustachian tube ; Wendt, once in the tubes, and twice, in 
eighty-four cases of variola, in the middle ear, together 
with naso-pharyngeal cavity (Thierfelder Atlas histol. 
Anat., tab. I.). Wreder saw a case of primary diphtheria 
in the external ear. 

EPIGLOTTIS, LARYNX, AND TRACHEA. 

The descent of the diphtheritic process into the respira- 
tory organs may give rise to various conditions. The 
membrane is not always found to pass uninterruptedly 
from the mucous membrane of the fauces into the larynx ; 
not infrequently isolated diphtheritic spots are found in 
the pouches on either side of the attached extremity of 
the epiglottis. At such times, the epiglottis is moderately 
swollen, its margins hard and reddened. Occasionally the 
redness is interrupted by small diphtheritic deposits which 
may remain isolated for a considerable time, but finally 
coalesce so as to coat the edges of the epiglottis with a 



76 A TREATISE ON DIPHTHERIA. 

continuous membrane. As a rule, the upper surface of the 
epiglottis is not completely covered by membrane, while 
only now and then diphtheritic deposits are found on its 
under surface. 

A most extraordinary case of diphtheria of the epiglot- 
tis I have seen in company with Dr. Wm. Balser. A girl 
of four years was attacked with pharyngeal diphtheria of 
rather a mild type, the general condition being fair, and 
fever moderate. In due time mild symptoms of croup set 
in, moderate hoarseness, dyspnoea, and croupy cough. 
The epiglottis was a little hyperasmic, but not all over. 
On some hyperasmic spots, but also on those of normal 
color, diphtheritic deposits would show themselves, but 
the appearance of a hyperasmic spot would not necessitate 
a subsequent diphtheritic membrane. The deposits were 
never large, never at anytime covered so much as one-third 
of the margin of the epiglottis at the same time ; their first 
appearance being on the left, it took more than two weeks 
before this spot got clean again ; meanwhile, a few isolated 
little deposits took place on the centre and to. the right, the 
disappearance being as slow as the development. The 
whole process lasted a month in this way, the croup 
symptoms being well pronounced, but of a mild type. 

The subjective symptoms accompanying the affection of 
the epiglottis are not always in direct proportion to the 
extent of the membranes. Dyspnoea and hoarseness occa- 
sionally occur where the only abnormal condition is a 
marked oedema at the entrance of the larynx, particularly 
of the posterior wall near the arytenoid cartilages and the 
attachment of the vocal cords. The ©edematous condition 
causes a functional paralysis of the vocal cords, together 
with marked dyspnoea on inspiration. The difficulty of 
breathing may become so excessive that the clinical diag- 
nosis of croup is unquestionable, and tracheotomy resorted 
to, while expiration is comparatively free, and the voice 
not markedly affected. Furthermore, cases occur in which 
there is no marked oedema, but merely a general catarrh of 






SYMPTOMS. JJ 

the epiglottis and larynx ; here, too, the subjective symp- 
toms of hoarseness and dyspnoea may become severe, and 
necessitate the performance of tracheotomy. Still, bearing 
this in mind, I have on several occasions refrained from 
performing this operation, where I judged that, aside from 
the diphtheria of the pharynx, I had to deal with a moder- 
ate oedema of the glottis or a laryngeal catarrh. 

Frequently, however, membranes form in the larynx in 
the same way as in the pharynx or nose ; then inspiration 
and expiration are equally interfered with, and hoarseness 
is a more constant symptom than in the above-mentioned 
cases. Fever and pain are not necessarily prominent 
symptoms ; in fact they are frequently unimportant, but 
in proportion as the degree of narrowing of the larynx 
increases, the respiration becomes more difficult, long- 
drawn, and loud, in the place of hoarseness. There is com- 
plete aphonia, and the hoarse, loud, barking, "croupy" 
cough becomes more "husky and suppressed, without los- 
ing all of its croupy character. This narrowing may con- 
tinue and increase for days, when suddenly a paroxysm of 
severe dyspnoea comes on. The child can no longer lie 
down, becomes pale, livid, and bluish, its skin is covered 
with perspiration, it supports itself on its hands and knees. 
The inspiratory act is slow and whistling, expiration short 
and shallow, pulse becomes intermittent, and as the con- 
dition of carbonic acid poisoning comes on, convulsions 
ensue from time to time. Such a paroxysm sometimes lasts 
considerable time, leaving the patient in a worse condition 
than before the attack. It is immaterial whether the dys- 
pnoea be sudden or gradual ; in either case the respiratory 
muscles have an unusually severe task to perform. The 
supraclavicular and intercostal regions are retracted with 
each inspiration, and in severe dyspnoea the ensiform 
process takes part in the exhausting respirator}' efforts. 
Long before this, the vesicular murmur cannot be heard 
on auscultating the lungs, for the normal respiratory sound 
is masked by the laryngeal noises, even though the lungs 



78 A TREATISE ON DIPHTHERIA. 

had not as yet been directly implicated. Paroxysms may 
recur again and again, invariably leaving the patient in a 
worse condition. Occasionally the child dies in such an 
attack, at other times the paroxysm appears to bring 
about a state of comparative comfort, the child remains 
more or less cyanotic, becomes oblivious to surroundings 
under the anaesthetic influence of the carbonic acid poison- 
ing, and finally dies of asphyxia. Anaesthesia, however, 
is not so frequent as some writers appear to believe. This 
is the picture of membranous croup, as seen during the 
long and wide-spread epidemic of diphtheria, that has 
lasted up to the present day, these twenty-two years. 

As a rule, a number of days elapses between the appear- 
ance of the first laryngeal symptoms and death ; at times, 
however, the laryngeal symptoms appear very suddenly, 
and may lead to a fatal result in a few hours. This is pos- 
sible where there has been a very large formation of mem- 
brane within the larynx, but it usually occurs only when 
the trachea and bronchi were the first to become the seat 
of diphtheritic deposits, the larynx escaping infection in 
the beginning. It may happen that the trachea and 
bronchi may become affected, although diphtheria of the 
fauces do not exist. This does not occur as rarely as 
Henoch and Oertel seem to believe. The former thinks 
that diphtheritic tracheo-bronchitis is taken to be the 
primary condition, because the throat is not examined 
early enough. He gives his opinion on a case (Charite- 
Annalen, Berl., 1876) in the following words : " On exam- 
ining the throat of a four-year-old boy, upon whom Henoch 
had performed tracheotomy, November 20th, 1873, nothing 
further than redness could be detected, and on autopsy 
there was naught but hyperaemia of the velum, tonsils, 
and pharynx, and a swelling of the tonsils. But low down, 
underneath the base of the tongue, on either side of the 
epiglottis, the mucous membrane was covered by diph- 
theritic membrane, which spread from thence far down 
into the bronchial tubes." Henoch's statement in refer- 



SYMPTOMS. 79 

ence to this case is lucid enough, but the above-described 
condition allows of another interpretation. If the case 
was of long- duration, it is probable that Henoch's theory, 
that the throat was not examined early enough to observe 
the downward passage of the disease, is appropriate. 
But the cases that run a rapid course, and the invasion of 
which is akin to a thunderbolt, are those that began below 
and extended upward. 

Oertel is of the opinion that the membrane in the fauces 
is overlooked in such cases. Steiner, too (Ziemssen's 
Handb., IV., i, 236), thinks that " the tendency of the times 
is to question, nay, rather to deny, the existence of croup 
extending from below upward." Now, on the contrary, 
repeated experience enables me to assert with positive- 
ness that diphtheritic tracheo-bronchitis may occur with- 
out an affection of the pharynx at the same time. I do 
not deny that it may last for days without giving rise to 
dangerous symptoms. I know it does. But when the 
process reaches the larynx, the symptoms of suffocation 
become so urgent that tracheotomy may be absolutely re- 
quired at once, and, in spite of the operation, death soon 
after occurs. 

It is characteristic of these cases that when, immediately 
after tracheotomy, a feather be introduced through the 
tube, the contact thereof with the trachea below the ex- 
tremity of the tube will not give rise to coughing. In 
about fifteen such cases, or more, I have performed trach- 
eotomy on, I have seen the first speck appear in the 
pharynx the same day, or soon after ; and, where the 
children lived long enough, say twenty-four hours after 
the operation — a rare occurrence, though — the speck had 
spread into a large membrane. In one case in which I 
performed tracheotomy, and no membrane and but slight 
swelling of the fauces could be detected during life, an 
autopsy revealed no deposits in the fauces, but the larynx, 
trachea, and several ramifications of the bronchi contained 
diphtheritic membranes. Nor is it possible that, when death 



80 A TREATISE ON DIPHTHERIA. 

ensues rapidly from suffocation, the process should have a 
sufficient time to spread upwards to the pharynx. 

Of course, these cases are exceptions ; as a rule, laryng- 
eal and tracheal diphtheria result from a descent of the 
disease from the fauces. More or less uncomplicated 
cases of primary laryngeal diphtheria, or so-called sporadic 
membranous croup, were, however, observed before the 
end of the sixth decade of this century. They were then 
almost the only cases of diphtheria, and linked former 
epidemics and the present one together. Further explan- 
ation of this subject will be found below, in my anatomical 
remarks. 

INFLAMMATORY AFFECTIONS OF THE LUNGS 

may occur at various times and in various forms during 
an attack of diphtheria. That which appears after tracheo- 
tomy is usually a broncho-pneumonia, the result of rare- 
faction of the air in the respiratory passages during the 
period of impeded inspiration, with consequent collapse of 
pulmonary tissue and dilatation of the blood-vessels, and 
hence a disturbance of the circulation ; it may not fully 
develop until after tracheotomy, and is a frequent cause of 
death on the second or third day succeeding the operation. 
Now and then a case of lobular pneumonia will result 
from the aspiration of pieces of membranes into the 
smallest bronchi. It can be easily recognized when 
the trachea is opened, but previous to the operation 
the auscultatory signs are of little or no value, being 
masked by the laryngeal rales. Percussion is equally use- 
less, for a dulness might just as well indicate collapse of 
the lung as infiltration. The second form of pneumonia 
associated with diphtheria, whether of the pharynx or 
larynx, is from the beginning fibrinous in character. 
Here, too, auscultation and percussion are of little assistance 
in establishing a diagnosis, when there is a laryngeal diph- 
theria at the same time, for the above reasons. Where, 
however, the dulness on percussion is accompanied by 






SYMPTOMS. 8 1 

high fever, and the long-drawn inspiration is replaced by 
rapid respiratory movements, we have reason to think of 
pneumonia as a complication. 

Roser and Pauli believe that pneumonia may result 
from the entrance of blood into the lungs during tracheo- 
tomy ; this is denied by Steiner. The former view this 
question from the same stand-point as that taken by Nie- 
meyer when he imputed to hemorrhages in the minutest air- 
passages the power of bringing on inflammatory changes 
in the respiratory apparatus. I am in a position to testify 
to the truth of his remarks, from having myself witnessed 
such a phenomenon. Having performed tracheotomy in 
a healthy, ten-month-old child for a foreign body in the air- 
passages, the child died on the operating table an hour 
after the opening of the trachea, before the necessary at- 
tempts at extraction had ceased. A number of the small- 
est bronchial tubes contained blood, which had flowed in 
during the protracted operative proceedings ; around these 
collections, the lobuli were collapsed and pale. No doubt 
these spots would have become the seat of fluxionary hy- 
peraemia and inflammation had the process been continued, 
unless a removal of the blood-clots had ensued, which I 
should consider very improbable indeed. 

DIPHTHERIA OF THE MOUTH, 

as a primary affection, is not of very frequent occurrence ; 
not rarely, however, is it associated with diphtheria of the 
fauces and nose, mainly when they have assumed a septic or 
gangrenous character ; it appears on cheeks, tongue, angles 
of the mouth and gums, and after the fetid discharges 
have excoriated the skin, on the lips also. In all of these 
localities it appears less in the form of an extensive, thick 
membrane than an infiltration of the tissues, to wit : in and 
under the mucous membrane, in the accidental fissures of 
the tongue and corners of the mouth. It is most apt to 
occur where, from the start, the mucous membrane of the s 
mouth presented a solution of continuity. The ulcerated 
6 



82 A TREATISE ON DIPHTHERIA. 

base of a follicular stomatitis is very frequently the start- 
ing-point of a general diphtheria of the mouth. It is always 
a disagreeable symptom, points to a long duration of the 
whole process, and threatens septic absorption. , 

(ESOPHAGUS AND THE CARDIAC PORTION OF THE 

STOMACH 

are the seat sometimes of very massive and extensive, mostly 
fibrinous exudations, in typhoid fever, dysentery, cholera, 
measles and scarlatina, or after injuries following the con- 
tact with mineral acids, alkalies, corrosive sublimate, or 
antimony. When the normal tissue was not injured, 
I never saw any that were not superjacent and could not 
easily be peeled off (" croupous "). Rokitansky reports, 
however, cases of genuine infiltration of the tissue 
(" diphtheritic "). Most of these exudations are whitish 
or grayish-white. Addition of haematine is apt to give it 
a brownish admixture. A case of L. Letzerich's (" mykosis 
oesophagi," in Arch. f. Pathol, u. Pharmac, VII., p. 33) 
does not belong here, probably. A girl of one and a half 
years had now and then severe pain in swallowing, had no 
appetite and no sleep ; after a few days, stomach large 
and tympanitic, no fever, not much vomiting. Nothing in 
the pharynx. The pain during deglutition finally pointed 
to the oesophagus. Oesophageal epithelium (none from the 
stomach), broken up and degenerated, also micrococci are 
reported to have been found. It was also learned that the 
baby had picked off and eaten rotten wall-paper. The 
locality of the affection could be explained only by assum- 
ing that there was, previously to the passing down of the 
micrococci to the stomach, where they would have been de- 
composed and rendered harmless, a sore spot met with in 
the mucous membrane of the oesophagus. But the follow- 
ing case is a better illustration of what I mean. I met in a 
three-year-old child in a tenement house in Thomas street, 
some eighteen years ago, during well-developed typhoid 
fever, with a fibrinous exudation, beginning in the pharynx 



SYMPTOMS. 83 

and filling the whole of the oesophagus, the cardiac portion 
of the stomach being also covered with a slight film. Dr. 
W. S. Greenfield presented to the London Pathological 
Society (Trans., vol. XXIX., 1878, p. 29) the case of a 
female child, aged five years, who during life and at the 
autopsy exhibited all the symptoms of enteric fever, and 
also on the tongue, throat, larynx, and the upper part of 
the trachea, the false membrane of the usual diphtheritic 
character. 

According to Zenker and v. Ziemssen, the membrane of 
pharyngeal diphtheria is said to suddenly cease at the 
entrance into the oesophagus. This has not been so in my ex- 
perience. The upper part of the oesophagus, over a surface 
of one to three centimetres (one-half to one inch), is often 
covered in cases of extensive pharyngeal and laryngeal 
diphtheria. The upper portion of the deposit is very much 
like the adjoining pharyngeal membrane, but the lower 
part is thinning out into a mere film, soon. I found it to be 
so in many autopsies of membranous croup. On the other 
hand, I met with a case in which the diphtheritic deposit 
was found in the lower part of the oesophagus only. It 
was that of a boy of four years who suffered from an al- 
most impenetrable stricture of the oesophagus (produced 
by his swallowing lye a year previously), when he was 
admitted to my service in the Mount Sinai Hospital. 
Careful dilatation was resorted to, which was interrupted 
frequently and just as often recommenced, until he began 
to partake of solid food. After a period of what appeared 
to be a common bronchial catarrh, attended with but oc- 
casional fever, serious dyspnoea set in, and the child died 
after a brief attack of fibrinous tracheo-bronchitis. The 
usual results of the post-mortem examination of the respir- 
atory organs were not even so interesting as the condition 
of the oesophagus. Its entire length was normal, with the 
exception of a circular portion about three centimetres 
in length, commencing about twelve centimetres (five 
inches) from the upper end. It proved absolutely im- 



84 A TREATISE ON DIPHTHERIA. 

penetrable to the smallest silver probe, while but a few 
days previously the patient had swallowed semi-solid food. 
The cause of the obstruction was found to consist of a 
deposit on, and infiltration into, the cicatricial tissue. 
Now, cicatrices are not very apt to be affected unless their 
surface is eroded. It is highly probable that the difficulty 
of deglutition, and the frequent use of the bougies, pre- 
pared the oesophageal stricture for the diphtheritic deposit 
which has been alluded to. 

INTESTINAL DIPHTHERIA. 

My experience concerning intestinal diphtheria is not 
large. Of course, I except dysenteric affections. In 
one case, that of a three-year-old boy (a fatal case of 
diphtheria of the throat had occurred in the same house 
the year before), the symptoms were fever, moderate 
tenderness of the abdomen without much tympanites, 
constipation, and great prostration. The diagnosis was 
enteritis. An autopsy revealed diphtheritis, having its 
seat in the jejunum and ileum. The membranes consisted 
of a dense network with granular contents and but slight 
intermingling of mucus. In the cow, croupous enteritis is 
frequent. Tubular casts of two metres in length, one of 
nine metres (which was passed at one time in eleven seg- 
ments, and contained numerous specimens of taenia denti- 
culata) have been observed (O. Bollinger, in Deutsch. 
Z. f. Thiermed., ist suppl., 1878, p. 18). Weissenfels has a 
case of diphtheria of the gall-bladder from irritation by a 
calculus (Inaug. Dissert., 1868). I. Zit (Jahrb. f. Kind., 
1879) found most cases of intestinal diphtheria in the large 
intestines, not counting the cases of dysentery, which in 
his experience was often met with in complication with 
pharyngeal diphtheria. Still in the upper portion of the 
intestinal tract diphtheritic enteritis was by no means 
rare. The deposits were quite thin, sometimes, but were 
characteristic in their composition. Still I warn against 
a mistake which can easily be made unless the microscop- 



SYMPTOMS. 85 

ical examination of the long tough membranes be resorted 
to. Such membranes consist sometimes of nothing but 
mucus, hardened and flattened down by long compression. 

WOUNDS. 

Wounds of all kinds are easily and rapidly infected by 
diphtheria. I have already spoken of the diphtheritic in- 
fection of vaginal abrasions and also of erosions of the ex- 
ternal ear, tongue, and corners of the mouth. Scarifica- 
tion or removal of part of the tonsils is followed in half a 
day or a day by a deposit of diphtheritic membrane on the 
wound. The wound caused by tracheotomy becomes in- 
fected with diphtheria within twenty-four hours. Leech- 
bites, skin denuded by vesicatories, removal of the cuticle 
by scratching during cutaneous eruptions, all furnish a 
resting-place for diphtheria in a short time. Larger 
wounds, as those of amputations and resections, may 
speedily become covered by diphtheritic membrane and 
thus easily lead to death. I have seen two cases of resec- 
tion of the hip-joint in my own practice which ended fatally 
in a short time by complication with diphtheria. There- 
fore. I have made it a rule to operate as little as possible, 
while an epidemic is raging, particularly in the mouth. 

Billroth has given the name of 

MUCO-SALIVARY DIPHTHERITIS 

(Allg. Chir. Pathol, u. Ther., 8. AufL, 380) to an affection 
ensuing after extirpation of a large portion of the tongue, 
and resection of the lower jaw. The local changes consist, 
primarily, a in very hard and rather wide-spread infil- 
tration of the cellular tissue about the wound, followed by 
its rapid pulpous degeneration. Most of these cases ter- 
minate fatally by septicaemia, some favorably by profuse 
suppuration starting from beneath the local necrosis of 
tissue. The patient is menaced by this disease only dur- 
ing the five days succeeding an operation, as it never 
occurs later than this. When healthy granulations have 



86 A TREATISE ON DIPHTHERIA. 

already appeared, this form of diphtheria cannot occur, 
and should diphtheria attack the wound, it is due to a dis- 
turbance of the granulations, thereby allowing the disease 
to be introduced from without. The general symptoms 
of this affection may be very severe, and collapse ensue 
very early. 

SKIN. 

At times immediately at the beginning of an inva- 
sion of diphtheria, at other times only on the second 
or third day, an erythematous eruption, more or less 
general, appears on the skin. Now and then it appears on 
the chest, shoulders, and back ; at other times it covers 
the body, and has not infrequently led to its being 
confounded with scarlatina. It is not always accom- 
panied by much fever, and cannot therefore be mis- 
taken for that form of erythema which frequently appears 
in children with delicate skins during high fever from any 
source. I cannot say that I have found this complication 
to give a more malignant character to the disease, but 
true erysipelas does. I am not prepared to prove that the 
two processes, erysipelas and diphtheria, are identical 
under some circumstances, but the complication of the 
two, and the ferocity with which they combine, renders 
a close relationship probable. I have seen an infant 
dying from an erysipelas added to a post-auricular diph- 
theria, this being due to a slight abrasion of the surface. 
Erysipelas originating in the tracheotomy wound, though 
ever so carefully disinfected and secured, is frequently 
observed after two or three days, and is a very ominous 
symptom. And erysipelatous surfaces, denuded of their 
epidermis by spontaneous vesication, or injured by ever 
so slight a trauma, are very liable to be covered with 
diphtheritic membranes. 

DIPHTHERIA OF THE GENITOURINARY ORGANS 

does not often occur. However, I have proofs of its ap- 



SYMPTOMS. 87 

pearance even as a primary disease. The rarity of its occur- 
rence, and the fact that occasionally after delivery the abra- 
sions of the vagina, arising during labor, become covered in 
twenty-four hours with a diphtheritic membrane, would 
seem to indicate that, where diphtheria of the vagina is 
found in children, it is probable that the disease had its local 
foundation in a catarrh or erosion of that locality. Un- 
doubted cases of that kind I have seen several times in the 
course of the last few years. In but few cases I have seen an 
infiltration of the neighboring inguinal glands ; in but a sin- 
gle case can I positively claim to have seen diphtheria of the 
pharynx following a diphtheria of the vagina, this taking 
place in an adult, upon whom an operation was performed. 
But a single case of that description proves a great deal. I. 
Zit reports thirteen cases of vulvitis diphtheritica ; in some 
the local affection was the first symptom of generalized diph- 
theria, with partly superjacent, partly imbedded mem- 
branes. Diphtheria of the bladder has been described by 
Billroth as occurring on the mucous membrane of the uri- 
nary bladder .and vagina, where it is met with especially 
where the urine is alkaline, after lithotomy, urethrotomy, 
the operation for vesico-vaginal fistula, and in ectopia vesicae. 
This form of diphtheria has a marked tendency toward local- 
ization, but by extension of the phlegmon, when of putrid 
character, to the retro-peritoneal cellular tissue, a perito- 
nitis with fatal termination may ensue. Before this, how- 
ever, can take place, and with it, sepsis from absorption may 
occur. The diphtheritic inflammation of the vagina prob- 
ably sets up a superficial inflammation in the uterus and 
Fallopian tubes and may thence lead to peritonitis. Diph- 
theria of the vagina of a fibrinous character occasionally 
occurs after the operation for vesico-vaginal fistula, more 
frequently after delivery, when the disease usually has an 
unfavorable termination. I witnessed an extensive diph- 
theria of the vagina in a patient upon whom Dr. Emmet, at 
my request, performed an operation for prolapse of the 
vagina and extensive laceration of the cervix. The disease 



88 A TREATISE ON DIPHTHERIA. 

commenced in the wounds, which began to gape, and from 
thence spread over the entire vagina. In a few days diph- 
theria of the fauces appeared. Another operation became 
necessary, of course, which resulted favorably. At that 
time there was not a single case of diphtheria in Dr. Emmet's 
institution, the one in question forcing him to almost empty 
his hospital in order to get rid of the danger. No case of 
diphtheria occurred subsequently. In the case of this lady, 
the disease appeared to have affected her alone, for, in spite 
of the prevalence of the epidemic, neither in her house nor 
in the circle in which she moved had another case of diph- 
theria occurred. Diphtheria of the placenta was demon- 
strated to the German Surgical Society (VerhandL, 1877, 
p. 41) after having been proven to exist by Schiiller. The 
membrane was between uterus and placenta, and remained 
attached to the latter. It resulted from puerperal sepsis. 
Hueter also (Deutsche Z. f. Chir., 1877, p. 226) emphasizes 
the occurrence of diphtheria after urethrotomy and 
lithotomy. It may even occur after measuring stones 
for the purposes of lithotripsy ; thus he advises that injec- 
tions be made of mild solutions of carbolic acid. It is, how- 
ever, natural, if not in diphtheria, still in Hueter, who insists 
upon "monads " to complete the diagnosis of diphtheria — 
that these cases of diphtheria do not " count for full," that 
they are " pseudo-diphtheritic." To the rabbits concerned, 
however, it will be satisfactory to know that inoculation 
of these pseudo-diphtheritic masses into their backs de- 
stroyed life as readily as that of diphtheritic membranes 
from the larynx. For similar observations compare also 
Virchow in Charite-Annalen, 1875. 

I have repeatedly seen diphtheritic infection of cir- 
cumcision-wounds. A Jewish family, coming to New 
York from the interior of New Mexico several years 
ago, had among its younger members three boys of 
from six months to five years of age. As none of them 
were circumcised, the rite was undertaken on all three on 
the same day. The wound in every one became diphther- 



SYMPTOMS. 89 

itic within twenty-four hours, two taking a favorable 
course, the third (and that in the eldest) resulting in a con- 
siderable loss of substance. In none of these cases, likewise 
in none of those seen previously, was there a swelling 
of the inguinal glands, but in the last-named, oldest boy, 
pharyngeal diphtheria showed itself within a few days, but 
healed long before the penis healed and cicatrized. Dr. 
Lange also (Med. Rec, July 10th, 1880) saw a baby of 
three weeks, who had been ritually circumcised while 
there was diphtheritic sore throat in another child of the 
same family. A membrane covered the preputial sur- 
face, besides two diphtheritic patches on the scrotum. 

Four years ago, I operated on a healthy boy of three 
years for phimosis. A simple incision through the upper, 
anterior part of the prepuce was made and the wound on 
either side closed with stitches. Mild carbolic acid appli- 
cations were made immediately and permanently. Diph- 
theria of the wound developed on the following day. 
Antiseptic treatment was continued, and carefully attended 
to, and a number of stitches in swelled and rigid parts re- 
moved. The diphtheria extended over a part of the 
penis, erysipelas set in, of no great extent, however, and 
the child died four days after the operation. 

Ad. Stromszky (Jahrb. f. Kind., 1880, XV., p. 170) 
publishes a case of diphtheritic balano-posthitis in a boy 
of three years, with consecutive gangrene of the prepuce, 
which was complicated with lobular pneumonia and 
(metastatic) abscesses in both lungs, resulted in abscesses 
in both inguinal regions and a psoas abscess of the right 
side, and terminated fatally. 

A boy of four years, idiotic and choreic, and suffering 
from a high degree of phimosis, was presented at my col- 
lege clinic half a year ago. The phimosis gave rise to 
difficulty, in micturition, and great uneasiness and pain. 
Therefore, but not with a view of improving either idiocy 
or chorea, I performed the simple operation of incising 
the upper aspect of the prepuce. The wound was care- 



90 A TREATISE ON DIPHTHERIA. 

fully closed with a sufficient number of stitches, and an 
antiseptic application ordered. Nevertheless, in a very 
few days diphtheria of the wound set in, the whole pre- 
puce and a small portion of the penis became gangrenous, 
and it took all the attention of my clinical assistant, Dr. 
Golding, and a few students through more than six weeks 
to save the whole organ from destruction. Considerable 
deformity, however, took place. 

KIDNEYS. 

Of the internal organs, the kidneys take the most active 
part in the diphtheritic process. Wade, in 1857, was the 
first to speak more particularly of the presence of albumen 
in the urine, in diphtheria. Albuminuria is not always of 
significance, as it occurs in severe and mild cases alike, 
both before and after tracheotomy, and therefore is not con- 
nected always either with the height of the fever or the de- 
gree of dyspnoea ; at times it disappears in a few days, in 
other cases it is of longer duration. It is not invariably 
complicated with changes in the kidney, neither do we 
always discover casts or degenerated epithelial cells in 
the urine. In other respects, also, it does not behave like 
albuminuria in scarlatina. In the latter it appears seldom 
before the second week of the process, and frequently 
later, while in diphtheria it is often seen early. It some- 
times lasts but a few days, particularly in many cases 
which set in with a high fever, which rapidly diminishes, 
and terminates in speedy recovery. In these occurrences 
the presence of albumen appears to attend the rapid elim- 
ination of the poison. 

Albuminuria seldom lasts longer than a week, and is not 
often complicated with oedema, but sometimes it is but a 
symptom of a local or general nephritis, and then hyaline, 
epithelial, and fibrin casts, and granular cells, are found in 
the urine. Nephritis then assumes as serious a character 
as it proves to possess in scarlatina. Cases of nephritis, for- 



SYMPTOMS. 91 

tunately rare, in a very early period of diphtheria, run a 
rapid and often fatal course. 

THE HEART AND BLOOD 

are affected in various ways by the diphtheritic process. 
Where the disease runs a slow course, accompanied by 
high fever, a granular degeneration occurs, similar to that 
appearing in other acute infectious disorders, typhoid 
for example. In diphtheria, however, it would seem that 
this condition may arise even without marked elevation of 
temperature. The pathological changes in the heart pro- 
duced by diphtheria are not always the same. Ecchy moses, 
cellular hypertrophy, and granular degeneration have 
frequently been noticed after death where the symptoms 
had been severe. 

The result, of course, is considerable weakness of its mus- 
cular tissue, evidenced by the formation of local (Beverley 
Robinson) thrombi, general sluggishness of the circulation, 
dyspnoea, muffled heart-sounds, a cool and pale skin, and 
sudden death, preceded by a very feeble and frequent, 
sometimes, however, by a very slow pulse. Aside from this, 
there are actual cases of endocarditis during the course of 
diphtheria, or convalescence therefrom. It affects espe- 
cially the valves, and among them particularly the mitral. 
It is characterized by high fever, precordial pain, attacks 
of syncope, and a systolic murmur. 

In most of these cases the local deposit gave rise to the 
most important symptoms, but there are cases of diphthe- 
ria in which the constitutional symptoms are more promi- 
nent than the local ones. I have twenty years ago desig- 
nated these cases as diphtheritic fever (Amer. Med. Times, 
Aug., 1 860). Cases of this kind are characterized by the fact 
that, while severe constitutional symptoms, as high fever, 
prostration, and great danger to life exist, there are but 
few local phenomena, either in the fauces or elsewhere ; in 
fact the danger from the disease is often in inverse pro- 
portion to the extent of the membrane. Such cases can 



92 A TREATISE ON DIPHTHERIA. 

only be explained by the hypothesis that the poison, with- 
out obtaining local footholds in the pharynx, nares, or 
larynx, and without giving rise to local phenomena, is 
directly taken up by the lungs and at once carried into the 
general circulation. It may affect several organs, the 
heart, the nerves, the blood, and the glands. Wunderlich 
reports two cases of Hodgkin's disease, pseudo-leukaemia, 
which developed during diphtheria. Bouchut and Dubri- 
say believe to have found a leukocythsemic condition in 
diphtheria. The rapid decrease of red blood-cells, and a 
moderate increase of leukocytes was demonstrated by 
them, but the disproportion was not such as to necessitate 
the diagnosis of leukocythsemia. 

After all that has been thus far remarked concerning the 
localization of the deposits, and the possible differences in 
the symptoms, we can readily see that the course and 
mortality of diphtheria have a wide scope. 

Most cases of diphtheria of the pharynx and of the tonsils 
have a favorable termination, yet a positive prognosis can 
in no case be given with certainty. Still even in malignant 
epidemics the mortality is not very great, for even though 
there be a large number of severe cases in any one epi- 
demic, yet it is greatly overbalanced by the number of 
moderately severe and mild ones. True, not a few cases 
end fatally in several days, owing to the high fever, or to 
septic absorption, or nephritis, or croup, but the majority 
of cases end in recovery in one or two weeks. Yet diph- 
theria does not always take so regular a course ; not 
infrequently, after the pulse has become stronger, the 
appetite improved, the pharynx cleared, and the patient 
was apparently on the high-road to recovery, another 
attack occurs accompanied by fever, as before, and a rapid 
membrane formation. Occasionally two or three such 
relapses may occur in the course of three, four, or five 
weeks ; not to speak of the fact that those who have once 
suffered from diphtheria are more susceptible to the action 



SYMPTOMS. * 93 

of the diphtheritic poison than those who have never ex- 
perienced an attack of the disease. 

THE NERVOUS SYSTEM 

is in manifold ways implicated in the diphtheritic process. 
The direct and rapid introduction into the blood of a 
foreign substance has, in almost all cases, as its earliest 
symptom, fever. Still we may safely assert that, with the 
exception of certain individual idiosyncrasies, high fever 
does not always result from the rapid absorption of a large 
amount of poisonous material. For many a septic fever 
runs through its entire course without any noteworthy 
elevation of temperature. Naturally the quantity of the 
poison absorbed depends on its source as well as on the 
individual susceptibility, and we have not in all cases to 
deal with a large amount of absorbed material. It has 
seemed to me that a series of cases depended on a gradual 
and protracted absorption of the poison into the blood, 
during a period of time, in which either elimination would 
take place or the septic material would exhaust itself by 
the chemical changes it will always undergo in a certain 
time.* 

* Of a peculiar interest are the following facts, which prove that the sub- 
stances credited with being the very strongest poisons, not only exhaust their 
own powers, but turn into the very opposite of what they were before. Sal- 
kowsky, in older to increase the rapidity of development in bacteria colonies, 
added some ascitic liquor which had been kept three years and had gone 
through all stages of putrefaction. Instead, however, of increasing, it stopped 
the development of bacteria (Berl. klin. Wochensch., No. 12, 1875). E. 
Baumann found phenol — one of the strongest anti-bacteric poisons known — 
as the final termination of the process of putrefaction (Zeitschr. f. physiol. 
Chemie, I., p. 60). In addition, in the same way Brieger discovered another 
antiseptic agent, scatol (indol having been found previously), and E. and H. 
Salkowsky hydrocinnamonic and phenylacetic acids (Wernich, in Berl. kl. 
Wochensch., No. 5, 1880). Thus, after a while, every one of the infectious 
poisons may turn into its own antidote. Who knows but that the rapidity with 
which many who suffered from severe infectious fevers (mainly typhoid) regain 
thair former strength, and more than that, in a short time, depends on just 
such changes in the very poisons which in the beginning had the tendency to 
destroy life? 



94 A* TREATISE ON DIPHTHERIA. 

Thus in the course of time various localities and various 
centres become affected, and thus produce either cases of 
gradual or sudden collapse, or of gradual or sudden paraly- 
sis. The first case of gradual loss of strength and final 
death, in regard to which at that time I had no explana- 
tion to offer, was published by me in i860. 

The history was that of a strong, healthy boy of four 
years, who complained of painful deglutition, to a slight 
degree, and seemed languid and sleepy. At that time (it 
was in the autumn of 1857) no extensive epidemic had 
occurred in the city. The child did not appear seriously 
ill ; there were but slight changes in the throat, a moderate 
swelling of the tonsils, no unusual degree of local hyperae- 
mia, and but little deposit of membrane on each tonsil. 
The pulse was weak, ninety beats per minute, skin moder- 
ately warm, rather sallow and dry, extremities not cold. 
The child was prostrated, depressed, took but little food 
when it was given him, did not ask for any, and it appeared 
to afford him no satisfaction ; local pain was not present, 
with the exception of a slight discomfort when pressure 
was made over the tonsils ; bowels were constipated. The 
pupils responded ; the boy replied in a sensible manner to 
the questions put to him, but rather slowly and indolently ; 
there were no other brain symptoms present. Thus with 
the exception of the diphtheria of the fauces, having at 
that time seen no similar form of general diphtheritic in- 
fection, I could make no other diagnosis. By the second 
or third day, there were no changes other than that the boy 
seemed to grow more indifferent, depressed, and melan- 
choly, cared nothing for the efforts made in his behalf, and 
expressed neither wish nor repugnance. Meanwhile the 
throat symptoms became somewhat more marked, the 
membrane covered about two-thirds of the tonsils, did not 
extend downward, and did not implicate the respiratory 
apparatus further than to cause an occasional sigh to be 
heard. By the morning of the fourth day, no marked 
change had occurred, with the exception of an increased 



SYMPTOMS. 95 

debility. Thus the condition became gradually worse, al- 
though the child took some nourishment, occasionally utter- 
ed a few words, replied to questions, and apparently was 
in the full possession of his consciousness. The temperature 
sank,' the child became weaker, and died in the afternoon. 
With the exception of a more frequent recurrence of the 
sighs, and more rapid respiration from time to time, no 
change preceded dissolution. The autopsy yielded only 
negative results, the viscera did not appear abnormal, and 
were in general bloodless. The blood-vessels contained 
but little blood, thin and dark-colored ; with the exception 
of the throat, no diphtheritic membrane could be dis- 
covered. 

Of course, the results of this autopsy are very unsatis- 
factory. Microscopical examination of the tissues was not 
resorted to. 

Unfortunately, the above case happened nearly a quar- 
ter of a century ago, that is to say, before Zenker and his 
followers had discovered and described the parenchyma- 
tous inflammation and the granular degeneration brought 
about in most of the tissues by febrile and infectious dis- 
eases. The only lesion of value in my case was the dark 
color and feeble consistency of the blood, which has since 
been found, together with extravasations, friability, and 
granular degeneration of the tissues, and now and then 
collections of cells and granules between the fibres in cases 
of septic poisoning and sudden death. In such cases, 
Hiller and Mosler lay marked stress upon the degenera- 
tion of the muscular tissue of the heart, others upon heart- 
clots, depending either upon insufficient contraction of the 
heart, or upon thrombi which have formed in remote 
veins, owing to a sluggishness of the general circulation ; 
occasionally, too, upon thrombi arising in the small veins 
of the neck during the efforts at and interruptions of 
respiration by an attack of croup. Others, still, hold to 
the view that the sudden death is caused by an interrupted 
innervation of the heart. Now, either the pneumogastric 



g6 A TREATISE ON DIPHTHERIA. 

or the cardiac filaments of the sympathetic may be affected, 
and the symptoms will vary accordingly. Paralysis of the 
former will accelerate the pulse, degeneration of the sym- 
pathetic nerves will diminish its frequency, yet death may 
ensue in either case. The same variations, as far as heart 
and artery-beats are concerned, according to the locality 
of the degeneration, are seen in the ordinary forms of fatty 
degeneration of the heart in adults. The explanation of 
a large number of such cases of sudden death has to be 
sought for similarly to what we do for the symptoms 
pertaining to actual diphtheritic paralysis, cases of which 
have been reported now and then in the literature of the 
past, but which has been brought more vividly before the 
minds of the medical profession through the influence of 
Maingault's monographs on that subject (1854 and 1859). 
The differences between diphtheritic paralysis and some 
of the cases of sudden death are certainly those of degree 
and not of kind. 

It was long believed that the poison exerted a local 
influence on individual nerves or groups of nerves. Oertel 
takes it for granted that diphtheritic paralysis is a pro- 
gressive peripheral paralysis. At the same time, he holds 
that every case has its origin in the fauces, but confesses 
that diphtheritic paralysis is of a very peculiar nature, as 
it invades the nerves of a locality that has already, or 
appears to have, been restored to its normal condition, 
and occasionally attacks distant nerve territories either 
suddenly or gradually. Now, the hypothesis that diph- 
theritic paralysis originates under all circumstances in 
the arches of the soft palate is decidedly erroneous. A 
large number of observers report cases in which other 
parts of the body, for instance, the muscles of accommoda- 
tion of the eye, were the first to become affected. I have 
observed cases, as have likewise Buckey and Bartels, in 
which the arches of the palate were entirely spared, and 
the cases published by Scheby-Buch clearly demonstrate 
that a large number of cases run their course accompanied 



SYMPTOMS. 97 

by a paralysis of the accommodation muscles of the eye 
without a similar affection of the soft palate. A case of 
uncomplicated paresis of the apparatus of accommodation 
is reported by Demoux (Gaz. Hop., No. 108, 1877). Magne 
(des paral. diphther., Paris, 1878) claims the sense of taste to 
be affected with paresis before other paralytic symptoms 
make their appearance. Equally erroneous is the view of 
Oertel, that the severity of the paralysis depends on the 
severity of the original sickness, for not infrequently it is 
just those cases in which neither fever nor local phenom- 
ena were of marked intensity which are followed by paraly- 
ses. I also consider the statement that it is characteristic for 
the paralytic phenomena, beginning with those of the soft 
palate, to follow a certain order, in diphtheria, as unjusti- 
fiable as the other hypothesis. This, no doubt, frequently 
occurs, but nowhere have I met with so many exceptions 
to the rule as here. I have abundant evidence that there 
are many cases in which precisely the contrary holds true, 
that is to say, that it is characteristic of diphtheritic paralyses 
that they follow no certain course, passing by certain parts of 
the body and attacking others. 

It may be positively asserted that diphtheritic paralysis 
does not in every case depend on one and the same cause. 
Many cases may be identical with those arising from 
typhoid or from any severe infectious fever— variola, 
dysentery, etc. In some cases, paralysis has certainly at 
once crept forth, as it were, from the part first affected ; 
in others, paralysis has followed, or gone hand and 
hand with, a fatty or granular degeneration of the muscu- 
lar fibres, or with capillary hemorrhages and amyloid 
degeneration. In isolated cases, paralysis is certainly 
of central origin ; thus Buhl discovered apoplexies in the 
spinal ganglia and in the gray matter of the spinal cord. 
In other cases, it may be attributed to the facility with 
which nervous disturbances and hemorrhages arise in all 
cases of hyperasmia, particularly where the walls of the 
blood-vessels are but tardily restored to their normal con- 
7 



98 A TREATISE ON DIPHTHERIA. 

dition, and where, in a gradual but slow convalescence, 
the heart is stimulated to overwork. I was formerly 
inclined to explain most cases of diphtheritic paralysis on 
the assumption that, precisely during the period of conva- 
lescence, when the patient presumes to put his strength 
to the test, the insufficient nutrition of the coats of the 
blood-vessels lead to hemorrhages, or to serous effusions. 
Many cases I do not hesitate to attribute to anomalies of 
nutrition of nervous tissue caused by the poison, which, 
unaccompanied by high fever or an extensive membrane-for- 
mation in throat and nose, is slowly absorbed by the 
lungs. Even Trousseau and Maingault had attributed 
diphtheritic paralysis to general infection. This view is 
all the more appropriate in those cases in which the pro- 
cess begins insiduously, and gives rise to no very urgent 
symptoms. The higher the fever, the greater may be the 
aggregation of infectious matters in the blood, but in all 
probability the more rapid and thorough will be the pro- 
cess of elimination. This would best explain the fact 
that diphtheritic paralysis frequently spares the severest 
cases, while visiting 'the apparently mildest. Only when the 
local manifestations of diphtheria in the throat are very 
marked, can we presume with some degree of certainty that the 
latter, too, constitute the starting-point of the paralysis. In such 
cases the local paralysis, particularly when it begins early, 
depends first on the cedematous infiltration of the whole 
tissue, and further on a direct implication of the nerves or 
on their compression by the inflammatory products. I 
have remarked that in these cases, as a rule, general paraly- 
sis does not occur. On the other hand, in mild cases, 
paralyses of the superior and inferior laryngeal nerves, 
and of the spinal nerves supplying head and extremities, 
occur either separately or in manifold combinations. The 
fact that the paralyzed nerves do not necessarily belong 
to the same locality, would indicate that the circulation 
influences the distribution of the poison. I look upon this 
explanation as simpler and more rational than the one 



SYMPTOMS. 



99 



which supposes bacteria, starting at a certain locality, to 
bore their way through the tissues and the coats of the 
blood-vessels, until they are finally deposited in the muscles 
and nerves. Through the blood, the alkalinity of which they 
cannot endure, they could not be circulated into distant 
parts. It is true, however, that paralysis of the soft pal- 
ate occurs very frequently. When not present during 
the first few days of sickness, as a result of local deposits 
or of inflammatory swelling, it appears, as a rule, in the 
course of the second week, sometimes, however, only after 
several weeks have elapsed, and even during convalescence. 
It occurs at times alone, at other times together with a 
paresis or paralysis of the constrictors of the pharynx. Ac- 
cording to the extent of the paralysis, deglutition becomes 
difficult, fluids, when swallowed, regurgitate through 
the nose, and speech is interfered with, or these condi- 
tions do not manifest themselves very markedly. Next in 
frequency to paralysis of the soft palate comes paralysis of 
the power of accommodation of the ocular muscles. Eulenburg, 
after a large number of paralyses of single muscles of the 
eye had been reported and described, laid marked stress 
on the paralysis of the ciliary nerves, with consequent 
paralysis of accommodation, and asserts that this affec- 
tion is apt to be symmetrical. Paralyses of the rectus 
internus and externus occur less symmetrically, but more 
frequently alternate. 

Scheby-Buch gives a resume of all the material relating 
to paralysis of the power of accommodation of the eye that 
had collected in the clinique at Kiel from 1862 to 1869. 
Of 38 cases, 24 had resulted from diphtheria. Of these, 20 
had been diphtheritic affections of the throat, 3 of wounds, 
1 each of vagina and skin. In all of those cases of paralysis 
of accommodation after diphtheria, mydriasis was ab- 
sent, with one exception. In the other cases it was also 
but slightly marked. Diminished refraction occurred in- 
variably, disappearing with the restoration to health. 
Occasionally a lessening of the acuteness of vision was 



IOO A TREATISE ON DIPHTHERIA. 

noticed, which disappeared together with the paralysis of 
accommodation. The diagnosis could often be made by 
the failure to observe any change of position of the lens 
during changes of accommodation. Paralysis of accom- 
modation was complicated with paralysis of the soft pal- 
ate in ten cases, among which there was one case of para- 
lysis of the lower extremities in addition ; in nine cases it 
was uncomplicated, and Scheby-Buch therefore justly in- 
fers that paralysis of the soft palate is not a conditio sine 
qua non of the occurrence of paralysis of accommodation. 
He refers, in this connection, to Dixon, Rook, Pagen- 
stecher, and Roger, who have likewise seen cases of un- 
complicated paralysis of accommodation. Still the latter 
may occur from several days (Weber, 18) to six weeks 
after the appearance of paralysis of the soft palate. 

Next in frequency come paralyses of the lower and upper 
extremities. They rarely arise suddenly. As a rule, they 
involve a series of muscles at the same time, improving in 
the same order as the individual muscles became affected. 
After the paralysis has lasted some time, the circulation 
begins to suffer. The extremities now and then become 
bluish, cool, emaciated, nay even complete fatty degene- 
ration and atrophy have been observed ; such manifesta- 
tions as the latter are, however, exceptional. Not infre- 
quently the muscles of the neck are affected ; the head 
cannot then be held erect, or this is accomplished with 
difficulty. 

One of the cases of diphtheritic paralysis reported by F. 
Pennavaria (II Morg., Aug., Sep., 1877) is of great interest, 
inasmuch as he emphasizes the paralysis in the fingers, the 
occurrence of which has been denied by several authors. 
The diphtheria of the patient (boy of sixteen years) was cured 
in twenty -four days, but paralysis of the pharyngeal mus- 
cles and consecutive dysphagia followed. Four days after- 
ward, there were disorders of accommodation, which lasted 
a fortnight. After this, paralysis of both lower extremities, 
and paresis of several fingers. Complete recovery resulted 



SYMPTOMS. IOI 

from eight faradizations. His other case was that of a 
child of three years, whose pharyngeal diphtheria lasted 
sixteen days. Paralysis of the soft palate and pharyngeal 
muscles followed ; a month afterward universal anasarca. 
When it disappeared rather suddenly, oedema of the glottis 
set in. This also passed by, and deafness and paraplegia 
had their turn. When the boy was examined three years 
after, he was well, with the exception of permanently hard 
hearing. 

The bladder is rarely affected ; likewise the intestinal 
sphincters. Among the most dangerous cases are those in 
which the respiratory muscles are involved in the paralysis. 
If paralysis of the pharyngeal muscles be in so far danger- 
ous, and even fatal, that food may enter the larynx and the 
remaining air-passages and give rise to direct suffocation 
or to a secondary pneumonia, then paralysis of the respira- 
tory muscles must be looked upon as far more dangerous 
to life. I recollect one such case which followed a paralysis 
of the arches of the palate and another independent of 
any preceding paralysis of the palate. Though the pro- 
gress of diphtheritic paralysis in general be mild, and 
the prognosis in general favorable, these cases are apt to 
terminate fatally. There is more danger of such a result 
than of a permanent paralysis of nerves and muscles. True, 
there have been reports of permanent paralyses ; I have 
never seen any, however. I have even witnessed complete 
restoration to health after atrophy had lasted for months. 

Thus far I have spoken only of motor paralyses. They 
are by all means the more frequent, but sensitive paralyses 
may occur in the same manner. Frerichs and Gerhardt 
have called attention to pure anaesthesias. I have myself 
observed a pure anaesthesia of the upper portion of the 
trunk. The association of motor and sensory paralysis 
may also be observed, giving the appearance of locomotor 
ataxia. A case of ataxia following diphtheria has been 
described by Rumpf (Deutsch. Arch. f. klin. Med., 1877, 
XX., p. 120) ; another by R. Schulz (1879, XXIII. , p. 360). 



102 A TREATISE ON DIPHTHERIA. 

A fortnight after recovery from diphtheria was completed, 
the patient complained of double vision, deficient vision at 
long or short distances, and dizziness ; soon afterwards nasal 
voice, difficulty in swallowing, liquids returning through 
the nares, increasing debility in both arms and legs to such 
an extent as to render his gait unsteady; formication in 
the limbs, and anaesthesia of the soles of his feet. When 
the author first saw him, the muscular power of the ex- 
tremities, particularly the right, was diminished, but sen- 
sibility, with the exception of formication, intact. Pres- 
sure upon the trunks of the nerves of the extremities, and 
upon the ganglion supremum of the sympathetic was very 
painful. Gait unsteady, atactic, more with closed than 
open eyes. Patellar reflex entirely gone. Faradic examina- 
tion revealed the irritability of the radial nerves but little 
reduced, if at all ; nor is the galvanic examination any 
more conclusive. No degeneration of the muscular tissue, 
to judge from electrical or galvanic tests. No cerebral 
disorders whatsoever, for the dizziness was owing to the 
paretic condition of the rectus internus muscle. 

The treatment consisted of galvanization through mas- 
toid processes with six elements daily at first, every other 
day afterwards ; also positive pole on neck, negative on 
eyelids ; ascending current over cerebral column with 
sixteen to eighteen elements ; galvanization of extremities 
sufficient to yield muscular contraction, of soft palate 
with six elements. The paresis of accommodation was 
improved after six sessions, removed after twelve, that of 
rectus internus and palate cured after twenty. Treatment 
having then been interrupted for a fortnight until the sensi- 
tiveness of the nerves of the extremities passed by, seven 
more applications of the galvanic current removed both 
paresis and ataxy of the extremities, so that the patient re- 
turned to work. At that time, however, the tendon reflex 
had not returned at all.* 

*Deutsch. Arch. f. klin. Med,, 1879, XXIII., p. 360. 



SYMPTOMS. 103 

The results of electrical applications have frequently 
been noticed, but the reports differ as to their nature. 
The effect of the continuous current was found normal by 
Caspari and Rumpf, greatly diminished by Leube ; Krafft- 
Ebing found the action of the interrupted current gone, 
the galvanic normal ; Rosenthal and Jaffray, the former re- 
duced, the latter increased. In my hands, the response to 
electricity was not the same in all cases. Very frequently 
in the beginning the response to the induction current was 
normal, sometimes deficient ; to the galvanic current ex- 
aggerated ; after some time the power of both to excite a 
reaction diminished. But when we reflect on the numer- 
ous causes that may underlie the diphtheritic paralysis, 
and that we have not in every case to deal with one and 
the same process, it will become apparent that the reac- 
tion to the galvanic current cannot be the same in peri- 
pheral, spinal, or cerebral paralysis. The first are 
certainly more frequent. It is possible, however, that in 
future the very observation of the action of the current 
may be rendered useful for obtaining a local diagnosis. 

There are but few autopsies of cases which died of, or 
during, diphtheritic paralysis. There was considerable 
thickening of the spinal nerves at the junction of the 
posterior and anterior roots, with hemorrhages. The 
superficial connective tissue in these places exhibited a 
diphtheritic exudation (Buhl). There was in the sheath 
of the nerves in the cerebral and spinal meninges and in 
the gray substance of the cord voluminous nuclear infil- 
tration, in one case there were extensive hemorrhages in 
the spinal meninges, with nuclear proliferation in the gray 
substance of the cord (Oertel). Also disseminated men- 
ingitis with perineuritis of the neighboring roots, charac- 
terized by infiltration of nuclei between the nerve fibrillar 
(Pierret). Also degeneration of the palatine nerves and 
fatty disintegration of the palatine muscles (Charcot and 
Vulpian). Dejerine, in five autopsies, records an atrophy 
of the anterior roots secondary to a myelitic degeneration 



104 A TREATISE ON DIPHTHERIA. 

of the ganglia of the anterior horns. In two cases he re- 
ports finding the same changes in the intramuscular 
nerves, viz., liquefaction of myelin and loss of axis cylin- 
ders. 

Thus Buhl, Charcot, Vulpian, and Dejerine are unani- 
mous about an affection of the peripheric nerves and 
muscles. Oertel and Dejerine believe in a disease of the 
spinal cord. It is true that a disease of the gray sub- 
stance would fully explain the symptoms mainly of the 
bad cases, but what we know of poliomyelitis anterior, 
with which this affection would be identical, precludes the 
idea of that rapid, and almost certain complete recovery. 
Therefore, in most cases, diphtheritic paralysis consists of 
a trophic affection of the motory system, almost always 
peripherically in nerves and muscles, seldom, if ever, in 
the centre. This affection must be compared, in most 
bearings, with the degenerative processes taking place in 
the muscular tissue after typhoid fever, in the renal 
epithelium after infectious diseases, both of which give 
rise to serious results, with mostly a favorable termina- 
tion.* 

SUMMARY. 

The first invasion of pharyngeal diphtheria resembles 
sometimes very much that of a catarrhal pharyngitis. 
The latter is general. Local hyperasmia points to either 
trauma or diphtheria. 

Three forms of diphtheria are found in the fauces : the 
" croupous, " the " diphtheritic," and the " necrotic." 

Glandular swelling about the neck is not always very 
marked. The above three species of diphtheria may each 
be found in mild or severe attacks. The last is apt to be- 
come septic and fatal. Nasal diphtheria is either the con- 
tinuation of the process from the soft palate, or primary. 
It is complicated with and characterized by rapid swelling 
of the deep-seated facial glands in most cases. 

*See Dr. Fritz, Charite-Annalen, V., 1880, p. 255. 



SYMPTOMS. IO5 

A chronic catarrh of pharynx, nares, and larynx is some 
times observed after the acute attack. 

Diphtheria of the conjunctiva terminates often in de- 
struction of the sclerotic and prolapse of the iris. It is 
frequently the only symptom of diphtheria, and purely 
local. 

The ear is affected either through the Eustachian tube, 
or in and from the external auditory canal. 

Diphtheria of the epiglottis is rarely found extensively 
on the upper surface, more on the lower, and sometimes 
in more or less isolated spots on the free margin. When 
complicated with but slight laryngeal affection, the croupy 
symptoms are but mild. They are apt to be of long dura- 
tion. 

Local cedematous infiltration of the upper posterior 
portion of the larynx interferes with inspiration more than 
with expiration ; membranous deposits in the larynx with 
both, and result in the worst forms of " membranous 
croup." Tracheal diphtheria is mostly the result of de- 
scending laryngeal membrane. But there are cases of 
primary tracheal diphtheria which, when ascending, re- 
sult in speedy suffocation. 

The lungs may be the seat of either broncho-pneumonia 
from several causes, or fibrinous pneumonia. The diag- 
nosis is very difficult, both auscultation and percussion 
yielding but doubtful results, unless there is a sudden in- 
crease of fever and of respiratory movements. Blood 
entering the lungs during tracheotomy may result in 
broncho-pneumonia. 

Diphtheria of the mouth is not frequently primary, 
mostly secondary, and the deposits are first seen on sore 
surfaces. The same is true in regard to the oesophagus. 
Its upper portion is often affected in cases of pharyngo- 
laryngeal diphtheria. Solid fibrinous deposits are met 
with in typhoid fever, variola, and other infectious 
diseases. 

The intestine is affected with diphtheria (beside the 



106 A TREATISE ON DIPHTHERIA. 

dysenteric process) in its upper and lower portions. In 
animals very extensive intestinal diphtheria has been ob- 
served. 

Recent wounds are liable to be affected with every one 
of the three forms of diphtheria within a day, or later, 
after an operation. Local or general cutaneous erythema 
is sometimes found. Complications of diphtheria with 
erysipelas are not uncommon, and dangerous. The blad- 
der, in cystitis, or after operative procedures, vagina when 
eroded, prepuce when operated upon, and placenta are 
the seats of diphtheritic deposits. 

Albuminuria is frequent, is mostly not dangerous, ac- 
companies sometimes a rapid process of elimination of the 
poison, occurs often at an early period of the disease, does 
not depend on, nor does it increase, the fever, seldom lasts 
over a week, but is sometimes one of the symptoms of 
diffuse acute nephritis of a very grave character. 

The heart may suffer from defective innervation, granu- 
lar degeneration, thrombosis, or endocarditis. The blood 
may be of a dark color, but is not leukocythasmic. Pseudo- 
leukaemia, however, has been observed during diphtheria. 

Thus the course of diphtheria is very various, prognosis 
doubtful, relapses are frequent, the temperature of the 
blood is not pathognomonic, the amount and rapidity of 
absorption and elimination changing. 

The nervous system suffers often ; sometimes in the very 
beginning of the disease collapse is developing, and may 
lead speedily to a fatal termination. 

Diphtheritic paralysis is considered peripheral by 
some, central by others. It does not always commence in 
the soft palate ; the latter has been known not to partici- 
pate in the paralysis at all. The muscles of accommoda- 
tion are frequently affected, also the extremities, in some 
instances sensory nerves, sometimes the respiratory appar- 
atus with dangerous results. Paralysis occurs mostly 
during convalescence from diphtheria, exhibits no regular- 
ity in the succession of the parts affected, does not injure 



SYMPTOMS. 107 

the sphincters, and is in most cases amenable to treatment. 
While, in the majority of cases, the disease appears to 
strike the trophic fibres of the motory nerves, the action 
of the electric and galvanic currents is very variable. In 
but a few cases ataxy has been observed. 



108 A TREATISE ON DIPHTHERIA. 



CHAPTER VI. 

ANATOMICAL APPEARANCES. 

The membrane, or the granular infiltration are char- 
acteristic of diphtheria. The statement that the former 
occurs only when atmospheric air can gain access 
thereto, as A. D'Espine and C. Picot still hold (Man. prat, 
des mal. de l'enfance, 1877, p. 81), is plainly contradicted 
by its appearance on the mucous membrane of the 
lower intestines. The condition of the membrane is not 
unalterable, any more than the clinical symptoms of the 
disease, for according to different circumstances, epithe- 
lium, mucus, blood, and vegetable parasites are added 
thereto. The membrane can either be lifted from the 
mucous surface on which it lies, or is imbedded into and 
underneath it. In the first instance, it consists to a great 
part of fibrin, the result either of epithelial changes, or 
derived directly from the exuded blood-serum. E. Wag- 
ner considers epithelial changes the principal source. He 
makes no anatomical distinction between croup and diph- 
theria. The pavement epithelium becomes altered in*a 
peculiar manner. It becomes turbid, larger, dentated, and 
dissolves into a network; it is at first uninhabited, but 
serves later as the vehicle of newly formed cells. Rapid 
metamorphosis of epithelium, and an equally rapid new 
formation, are the conditions of a speedy and extensive 
membrane formation. The same changes occur in granu- 
lation tissue, the granulating surface of an ulceration in 
the mouth exhibiting the same process as the mucous 
membrane. In addition to the formation of membrane on 
the surface, there also occurs a considerable infiltration of 
the mucous membrane with pus-cells and granules ; be- 



ANATOMICAL APPEARANCES. IO9 

sides, the cellular tissue is studded with granules, its de- 
composition resulting in fine granular deposits in the 
tissues and necrotic destruction, which is looked upon by 
Virchow as the most important element in severe forms 
of diphtheria. 

These several conditions may occur independently, asso- 
ciated, or in succession. 

Classen, with E. Wagner, considers an alteration in the 
superficial layer of epithelial cells characteristic of diph- 
theria. They become amorphous and the entire mass in- 
distinctly reticulated ; this change becomes the more decid- 
ed the longer the membrane existed. Solution of caustic 
potash demonstrates peculiarly altered cells therein, the 
contents of which are finely granular. These dark gran- 
ules, which strongly refract light, are " perhaps identical " 
with the monads of diphtheritic blood described by Huter 
and Tommasi. " If so, the disease might be considered 
as beginning with an enormous proliferation of these 
minute bodies in the epithelial coating, followed by a 
local fatty degeneration of the mucous membrane." These 
bodies would, presumably, circulate in the blood. 

Wagner's doctrines are assailed by Boldygrew, who 
attaches importance to the parallel condition of the layers, 
and to the appearance of peculiar concentrically-lamel- 
lated spheroidal bodies endowed with a dark and granular 
centre. These have already been declared to be, in all 
probability, drops of exuded mucous secretion which then 
give rise to a peculiar configuration of the exudation. It 
is said that ciliated epithelium is never seen on a mucous 
membrane affected with croup ; but numerous papillary 
elevations consisting of granulation tissue and pus cor- 
puscles, each covered with a sheath, present themselves ; 
furthermore it is asserted that hemorrhages do not occur 
in croup as in diphtheria ; and whereas the latter is char- 
acterized by an infiltration of small cells, a finely granular 
reticulated product occurs in the former. According to 
Boldygrew, the membrane consists of successive coagula- 



110 A TREATISE ON DIPHTHERIA. 

tions of a fibrinous fluid which exuded from the diseased 
surface. 

Steudener opposes the views of Wagner, remarking 
that he has never seen the early stages of a metamorphosis 
of cylindrical epithelium such as Wagner describes in 
connection with the pavement epithelium of the pharynx. 
He does not believe in the probability of an exclusively 
endogenous origin of the cellular elements of croup mem- 
brane ; in fact, he doubts the occurrence of an endogen- 
ous formation of pus globules in epithelium. Croupous 
membrane, according to him, is formed by the migra- 
tion of numerous white blood-globules through the 
walls of the vessels in the mucous membrane, and by a 
direct formation of fibrin from the transuded plasma. In 
addition to this, the mucous membrane is stripped of its 
epithelium (except at the mouths of the acinous glands), 
and infiltrated with migrating cells. The latter are most 
numerous immediately under the surface, with the excep- 
tion of the thin, pale, superficial border of the basement 
membrane. The vessels and ducts of the glands thereby 
become compressed, and the glands distended. Migrat- 
ing cells are less found in the deeper tissues, where elastic 
fibres are in larger amount than superficially ; an extensive 
infiltration exists in the submucous tissues, especially 
about the glands and even in the connective tissue sur- 
rounding the cartilaginous rings of the trachea. Fresh 
croupous membrane consists of a delicate network, of 
homogeneous structure and shining appearance, in which 
numerous cells and the epithelium of the various layers of 
the trachea are imbedded. There are, moreover, places 
where the cells are few in number and here and there 
too, membranes consisting (according to Rindfleisch) of 
round, densely agglomerated cells. In old membranes, the 
cells are destroyed by granular degeneration and general 
maceration. Tenacious mucus with pus-cells and det- 
ritus are then found. 

The doctrine which claims that the diphtheritic process 



ANATOMICAL APPEARANCES. Ill 

is caused, excited, or aided by bacteria, has been sus- 
tained in the most varied manner by Hallier, Laycock, 
Wade, Huter, Oertel, Klebs, Eberth, and many others. I 
have discussed this question in an earlier part of this 
treatise. Karsten (Wien. med. Woch., 1873, 39) looks up- 
on bacteria as a pathological cellular formation, analogous 
to pus and yeast cells ; and asserts that they originate 
within the cells and are not introduced from without. 

Attempts at producing artificial diphtheritic membrane 
were made long ago. Already in 1826 Bretonneau, by the 
introduction of tincture of cantharides and olive oil into 
the trachea, succeeded in producing a " dense, elastic, 
reed-like membranous concretion." Delafond called 
" croup " into existence by the use of ammonia, oxygen, 
chlorine, corrosive sublimate, arsenic, and sulphuric acid. 
On the other hand, H. Mayer asserts that it is impossible, 
by means of ammonia, to produce a croup in the windpipes 
of animals which in the slightest degree resembles that 
occurring in human beings. Trendelenburg, after produc- 
ing membranes in the trachea by the use of a solution of 
corrosive sublimate (1:120) succeeded in hardening the 
entire mass with bichromate of potash, which it was im- 
possible to do with the most tenacious mucus. 

Rey observed croup in horses that inhaled smoke in a 
burning stable (Journ. de med. vet. de Lyon, 1850, p. 249). 
In the collection of the veterinary school of Zurich, there 
is a croup membrane from a heifer which had been ex- 
posed to a fire ; at Munich, one from the trachea of a 
horse, produced by forcibly injecting medicines into the 
nose. Hahn made an observation on cows, W. Ammon 
on horses, of long croup membranes, after the animals had 
been exposed to smoke and fire, and Oertel constantly 
insists on there being " no actual difference between croup 
as it ordinarily occurs, and that excited in the windpipe of 
a rabbit by means of ammonia. The color and texture, 
the physical, chemical, and histological characteristics are 
identical." In regard to this question of identity or non- 



112 A TREATISE ON DIPHTHERIA. 

identity, the very last writer on the subject, C. Gerhardt 
(Lehrb. d. Kinderkrankh., IV. ed., 1880, p. 297) expresses 
himself in the following manner ; " The difference between 
laryngeal diphtheria and croup, after having been so much 
emphasized, cannot be sustained any longer. It was 
claimed by anatomists that diphtheritic membranes were 
imbedded into and closely attached to the mucous mem- 
brane, the croupous, however, lay closely upon it and were 
easily separated from it, without leaving any ulceration 
behind. If that were so, we should always see diphtheria 
of the larynx changing into croup of the trachea. Not more 
successful is the attempt at an etiological distinction of 
the two forms, by assuming that diphtheria is epidemic 
and croup sporadic. I have myself observed and describ- 
ed a sporadic case which proved contagious. Besides, 
the schizomycetae connected with diphtheria exhibit great 
differences when we come to examine the descriptions and 
drawings."* On the other hand, C. Weigert (Virch. Arch., 
Vol. 70), who experimented on artificial croup produced 
by the application of caustic ammonia, has his own theory 
on the origin of the pseudo-membrane. It does not orig- 
inate in the epithelium, for this may be absent and still the 
membrane will develop. Thus it originates in parts 
belonging to the cellular tissue. He deems both Oertel's 
assertion, that the croup membrane results from the con- 
glutination of large protoplasma cells, and the assumption 
that the glands could yield a solidifying secretion, incor- 

* To what excesses the bacteriomania can guide the mind is, in contrast to 
the above, illustrated by A. Ott, in Prag. Med. Woch., No. n, 1880. Five 
days, eight days, and five weeks respectively, after three cases of pharyngeal 
diphtheria in two adults and one boy, he observed fever and pain about the 
chest. This pain did not follow the course of the nerves, and increased on 
pressure. Some days afterwards pneumonia was diagnosticated. One of the 
cases terminated fatally. The reader is coolly requested to take both pain and 
pneumonia as the result of parasitic infection depending on the preceding 
diphtheria, and is given his choice between either of two theories, viz., that 
the parasites migrated from the painful muscles (?) to the lungs, or that they 
invaded both muscles and lungs through the lymph circulation. 



ANATOMICAL APPEARANCES. 113 

rect. He looks upon the deposits as analogous to those 
on serous membranes. Every inflammation yields an exu- 
dation which may coagulate when the coagulating ferment 
is added. This latter is probably produced by the white 
blood-cells when in disintegration. But he does not say 
why it is that there is no such coagulation in suppurative 
processes, where the leukocytes are more numerous. And 
does the experiment with ammonia, which necessarily 
destroys the surface epithelium, solve the problem of the 
origin of membranes when the epithelium is not forcibly 
removed or destroyed ? 

Weigert also believes himself justified in establishing 
pathological differences of croup, pseudo-diphtheria, and 
diphtheria. A croupous inflammation means destruction 
of epithelium, which gives rise to a fibrinous exudation 
upon the surface, while the cellular tissue remains intact. 
The only difference between it and the pseudo-diphtheritic 
inflammation is looked for in the larger number of emi- 
grated white blood-cells. The superficial deposit consists, 
to a great part, of them and the fibrinous exudation. When 
there are but few leukocytes, the deposit is a network of 
fibrillse (" croup "). When there are many, the masses 
are more solid and voluminous (" pseudo-diphtheritis "). 
When, however, the tissue is changed into a hard sub- 
stance, resembling coagulated fibrin ; when the exudation 
does not exist on the surface, but takes place into the 
mucous membrane, the process is " diphtheria." Finally, J. 
Zahn publishes contributions to the pathological histology 
of diphtheria which are interesting and important. Careful 
examinations of various diphtheritic membranes, mostly 
taken from the living, induce him to establish three vari- 
eties, viz. : 1st, such as result from a peculiar degeneration 
of pavement-epithelium ; 2d, such as originate in the 
solidification of a muco-fibrinous, and 3d, of a fibrino- 
purulent exudation. Each of these varieties may contain 
colonies of micrococci (gliococci, megalococci, and bac- 
teria), but these organisms are neither essential nor are 
8 



114 A TREATISE ON DIPHTHERIA. 

they constantly met with. In the adjoining tissues, 
either normal or infiltrated with round cells, particularly 
in the uvula, the parasites were not found. Thus the 
author prefers not to venture upon a decided answer to 
the questions of their essentiality. 

Klebs, as may be expected from the position he always 
maintained in the diphtheria question, is less hesitating 
(Beitr. z. pathol. Anat., 1878, p. 11). He admits that the 
membrane may be, or is, the same histologically in all 
cases, no matter how much the clinical symptoms may 
differ, but adds that, in the diphtheritic membrane, there 
is a development of bacteria, of always the same character, 
and pathognomonic. The last word is a gratuitous appen- 
dage which is not proven, as we know. The constant repe- 
tition of the same statements does not render them any 
the sounder. 

However, the diphtheritic process does not merely con- 
sist of the changes in the pharynx and air-passages. Its 
fatal cases have afforded marked evidence of the implica- 
tion of most of the organs. Reimer's 17 cases give the fol- 
lowing post-mortem results : the lungs were hyperasmicin 8 
cases, twice the seat of pneumonia, and three times of em- 
bolic infarctions. In addition, emphysema in 12, oedema in 
6, atelectasis in 7, subpleural ecchymoses in 7, pericardial 
ones in 4. The heart-muscle had undergone fatty degen- 
eration in 6, and was the seat of ecchymoses of the size of 
a pin's head in 3. In addition to frequent hypersemic con- 
ditions of the abdominal viscera, emboli of the liver in 3 
(with capillary hemorrhages of the peritoneal covering in 
1), emboli of the spleen in 5, desquamative nephritis in 7 
(in 6 of which there were colonies of micrococci in the 
uriniferous tubules), cellular hyperplasia of the cervical 
and mediastinal glands in 14 (complicated in 6 with capil- 
lary hemorrhages in the glandular tissue). The blood was 
frequently normal, very often watery and dark, at times 
leukocythotic. 

In the heart, particularly the right, numerous thrombi in 



ANATOMICAL APPEARANCES. 115 

various stages of development were found; its muscular tis- 
sue was often in a state of fatty degeneration, or the seat of 
parenchymatous inflammation and hemorrhages. Bridges 
first called attention to the occurrence of endocarditis in 
diphtheria (Med. Times and Gaz., II., p. 204). Diphtheritic 
endocarditis, which, however, occurs more frequently 
with rheumatism, puerperal fever, diphtheria of wounds, 
pyaemia, and old valvular affections than in the course of 
an acute diphtheria, does not consist simply of a fatty 
degeneration and subsequent ulceration, but is a genuine 
diphtheritic process (Virchow) affecting the mitral valve 
more frequently than the tricuspid or pulmonary valves. 
It begins with hyperaemia and the exudation of plasma in 
the cellular elements, so that they appear larger and 
darker. The granulations which form are frail and easily 
destroyed, so that ulcers form on which fibrin is depos- 
ited, and whence it is conveyed as emboli into the " termi- 
nal arteries " (Cohnheim) of the spleen, nerves, brain, and 
eye. Infarctions may also occur in the valveless veins of 
these organs, giving rise rather to small multiple abscesses 
than to large purulent collections. Suppuration but rarely 
takes place in the heart ; the granular mass found there 
resists the action of ether and alcohol (parasitic? case- 
inous ?), and spreads throughout the cardiac parenchyma, 
so that perforation of the septum, and of the right auricle 
and aorta have been observed. 

Bouchut and Labadie-Lagrave, out of fifteen cases of 
diphtheria, met with a plastic endocarditis in fourteen, 
which became the source of emboli. Thus there were in- 
farctions of the lungs, at times in their centre colorless, 
at other times in a state of purulent degeneration ; super- 
ficial thrombi of the small veins of the heart, subcutaneous 
connective tissue, pia mater, brain and liver. In addition 
moderate leukocytosis. 

THE LUNGS 

exhibit, post-mortem, all sorts of inflammatory and con- 



Il6 A TREATISE ON DIPHTHERIA. 

gestive conditions and hemorrhages, as : oedema, catarrh, 
broncho-pneumonia, atelectasis, emphysema, ecchymoses, 
and large infarctions. 

THE SPLEEN 

(and occasionally the liver) is frequently large, congested, 
and friable, and studded with infarctions to a greater or 
less extent. 

THE KIDNEYS 

are either simply congested, or the seat of nephritis or in- 
farctions. The same forms of inflammation which accom- 
pany scarlatina, to wit, the desquamative and the diffuse, 
are here observed. The diffuse form is not of so frequent 
occurrence as in scarlatina, but sometimes extensive and 
dangerous. 

THE MUSCLES 

occasionally exhibit ecchymoses, and are at times the seat 
of parenchymatous inflammation, gray degeneration, and 
atrophy. 

THE LYMPHATIC GLANDS 

are frequently inflamed and swollen, either hard or 
doughy, cedematous or congested. Large abscesses 
rarely appear therein. It is more especially the gland 
tissue, and less the connective tissue of the glands, which 
takes part in the pathological process. The periglandular 
tissue very soon becomes involved, however. Necrotic 
foci have been described by Bizzozero. In relation to 
this and other matters, but lightly touched upon in this 
place, I refer to other parts of this work. 

In regard to the nature of the glandular and periglandu- 
lar swelling, F. Balzer and Ch. Talamon investigated 
the condition of the submaxillary and parotid glands. 
The main changes were found in the epithelium of the 
excretory ducts and acini ; 2d, in the connective tissue, and 



ANATOMICAL APPEARANCES. 117 

mainly in the pericanalicular connective tissue ; 3d, in 
the blood-vessels which are often congested ; 4th, in the 
lymph vessels which are dilated and filled with cells. 
In consequence of all this, the glands swell and become of 
a yellowish color. For some time, isolated swellings can 
be felt, afterwards they may join in a common extensive 
tumefaction, which yields a peculiar sensation of spurious 
fluctuation (Revue Mens., Juill., 1878). 

INTESTINAL CANAL. 

According to Virchow, diphtheria of the intestinal canal 
is characterized by fibrinous deposits on the surface and 
in the tissues of the intestine, with subsequent granular 
degeneration of the tissues. According to Rajewsky, a 
catarrhal process invariably precedes the diphtheritic af- 
fection of the intestines. The latter begins with deposits 
of fibrinous exudation in the mucous membrane and on its 
surface. Then follows the destruction of the tissues of the 
mucous membrane, and their conversion into a granular 
mass, containing albumen, to judge from its solubility in 
acetic acid. This process extends, and at the same time a 
hyaline metamorphosis of the blood-vessels in the affected 
tissues takes place. As long as the tissues remained un- 
changed, isolated micrococci and bacteria were observed ; 
as soon as the granular degeneration set in, the organisms 
appeared in colonies. In both conditions, i. e., even be- 
fore the tissues underwent alteration, lacteals filled with 
bacteria could be noticed in the submucous tissue. Ra- 
jewsky endeavored experimentally to ascertain the exact 
relation bacteria bear to diphtheria of the intestines ; by 
injecting a dilute solution of ammonia, he succeeded in 
creating an inflammation of the mucous membrane of the 
intestines. If now a fluid containing micrococci was in- 
jected into the blood of the animal, the parasites are said 
to have circulated freely until they reached the intestinal 
canal, where they held fast, multiplied speedily, and at the 
same time the hyaline metamorphosis of the blood-vessels 



Il8 A TREATISE ON DIPHTHERIA. 

was inaugurated. When no affection of the intestines 
pre-existed, or the animal had not been prepared as be- 
fore, diphtheria of the intestines was not observed. The 
latter was as little apparent after the injection of the ara- 
moniacal solution alone, nothing more than a temporary 
inflammation resulting. If, however, a putrid fluid was 
injected immediately after, death resulted in from twenty- 
four to thirty-six hours. Rajewsky infers as a result of 
these experiments that the injection of fluids containing 
bacteria cannot give rise to diphtheria of the intestines 
except after the mucous membrane of the intestinal canal 
has been prepared to afford a resting-place for it, by a 
preceding inflammation. It is thus presumed that para- 
sites play an important part in intestinal diphtheria. The 
inflammatory changes of the tissues of the mucous mem- 
brane are in intimate connection with the hyaline meta- 
morphosis of the blood-vessels. 

It seems to me that here, too, the nature of diphtheria 
has been coolly postulated in the interests of the parasitic 
theory. Exudation and granular degeneration are claimed 
by Virchow as the characteristic phenomena of diphtheria 
of the intestines ; exudation, granular degeneration, and 
a. multitude of parasites, by the defenders of the bacterian 
theory, who indissolubly connect the name and nature of 
diphtheria with the presence of parasites. Moreover, 
Rajewsky reports no changes brought about by the action 
of the parasites alone, and this is, after all, the most im- 
portant point, since the same changes have been observed 
where neither the influence nor even the presence of the 
bacteria could be verified as a factor in the process. 

Indeed, nowhere has the postulation of ideas and defini- 
tions been more confusing and detrimental than in the 
study of the nature of diphtheria. Of late it has been 
with many only a question of whether bacteria are pres- 
ent in the morbid product in order to declare it diph- 
theritic ; formerly, and even now, certain differences 
between "croup" and "diphtheria" were and are postu- 



ANATOMICAL APPEARANCES. II9 

lated, and I shall, therefore, add a few final remarks here 
on the question of the identity of these affections. 

Can pseudo-membranous croup be distinguished from 
laryngeal diphtheria? Ought these terms to be preserved 
separately ? Are they different processes ? Let us sup- 
pose two cases of membranous impediment in the larynx, 
the one with, the other "without, membrane in the 
pharynx, the other symptoms being the same, is one 
" diphtheria of the larynx," and the other " croup " ? Sup- 
pose again, a membranous stenosis of the larynx, to which 
is only later added a membrane of the pharynx, was the 
case originally one of " croup " which became a " diph- 
theria " later on ? Thirdly, take two cases of laryngeal 
stenosis, one with symptoms of suffocation only, the other 
having these symptoms together with adynamia ; is the 
latter " diphtheria " alone, the former only " croup " ? In 
my opinion, it is just as little possible to differentiate these 
diseases according to the seat of the morbid product, as 
it is justifiable to deny the title diphtheria to membranous 
pharyngitis when few general symptoms, such as fever, 
debility, and collapse, happen to be present. 

Even Monti declares croupous laryngitis to be a separ- 
ate disease, independent of diphtheria, but considers that 
it may arise from a diphtheritic contagion ; he still, how- 
ever, treats of the disease in two distinct chapters, calling 
the one laryngitis crouposa, the other laryngitis diphtheri- 
tica. On the other hand, it is a well-known fact that 
Senator and the microscopists have declared these diseases 
to differ in degree, although identical in character. 
Fleischmann thinks that the pathological picture is obscured 
by the occasional combination of croupous and diphthe- 
ritic laryngitis, but that such cases are the last ones from 
which any conclusions should be drawn, and " it would 
seem as though these were the very cases employed pref- 
erably by some physicians to perpetuate the confusion " 
(Oest. Jahrb. Pad., 1875, I.). I fear that "thou art the 
man," and that we can promise ourselves little from the 



120 A TREATISE ON DIPHTHERIA. 

tendency to subdivide and subclassify nature. She does 
not work in narrow schedules. Still, not even last year's 
discussion in the Royal Medico-Chirurgical Society led 
the members to harmonious convictions.* 

The different forms of the diphtheritic affection, as I 
have described them, have a particular preference for cer- 
tain localities. When the entire mucous membranes of 

* The conclusions arrived at by its committee, appointed to examine into 
the relations existing between " croup " and "diphtheria," are as follows (re- 
port presented by Mr. Andrews) : I. Membranous inflammation confined to 
or chiefly affecting the larynx or trachea may arise from a variety of causes, as 
follows : (a), from the diphtheritic contagion ; (b), by means of foul water, of 
foul air, or other agents, such as are commonly concerned in the generation or 
transmission of zymotic diseases ; (c), as an accompaniment of measles, scarla- 
tina, or typhoid, independently of any ascertainable exposure to the especial 
diphtheritic infection ; (</), it is stated, on apparently conclusive evidence, 
that membranous inflammation of the larynx and trachea may be produced by 
various accidental sources of irritation — the inhalation of hot water or steam, 
the contact of acids, the pressure of a foreign body in the larynx, and a cut 
throat. 2. There is evidence in cases which have fallen under the observation 
of members of the committee, that membranous affections of the larynx and 
trachea have shortly followed exposure to cold, but their knowledge of the 
individual cases is not sufficient to exclude the possible intervention or co-ex- 
istence of other causes. The majority of cases of croupal symptoms directly 
traceable to cold appear to be of the nature of laryngeal catarrh. 3. Mem- 
branous inflammation, chiefly of the larynx and trachea, to which the name 
" membranous croup " would commonly be applied, may be imparted by an 
influence, epidemic or of other sort, which in other persons has produced 
pharyngeal diphtheria. 4. And, conversely, a person suffering with the mem- 
branous affection, chiefly of the air-passages, such as would commonly be 
termed membranous croup, may communicate to another a membranous con- 
dition, limited to the pharynx and tonsils, which will be commonly regarded 
as diphtheritic. It will thus be seen that, in the opinion of the committee, 
these two diseases are identical. It is suggested that the term " croup " be 
henceforth used wholly as a clinical definition, implying laryngeal obstruction, 
occurring with febrile symptoms in children, which may be membranous or 
not membranous, due to diphtheria or not so. The term "diphtheria" is the 
anatomical definition of a zymotic disease, which may or may not be attended 
with croup. It is admitted, however, that when obviously occurring from a 
zymotic cause or distinct infection, and primarily affecting the pharynx, con- 
stitutional depression is more marked, and albuminuria is more often and more 
largely present, though in both conditions some albumen in the urine is more 
frequently present than absent. 



ANATOMICAL APPEARANCES. 121 

the mouth and of the air-passages, from the nose to the 
trachea, are the seat of the disease, there is an impregna- 
tion of the mucous membrane from the epithelial surface 
to the submucous tissue of the entire tongue, borders of 
the lips, and frequently of the lips and cheeks, as well as 
of the tonsils, the lower portion of the nasal cavities and 
the upper and especially the anterior portion of the 
larynx. The fossas Morgagnii and the posterior aspect of 
the soft palate are more frequently affected in the same 
way than the anterior aspect. Small isolated spots are 
found on the tonsils and occasionally on the posterior 
wall of the pharynx. The so-called croupous form, that is 
to say, the one in which the membranes deposited may 
either be removed in large patches, or lie macerated in 
the profuse secretion of subjacent mucous glands, is 
found partly in the nasal cavities, on the posterior surface 
of the soft palate, in the trachea, and its subdivisions. 

The tissues in general, and the mucous membrane in 
particular, have been supposed to be endowed with cer- 
tain peculiarities which enabled them to markedly influ- 
ence the diphtheritic process. Eberth has directed atten- 
tion to the fact that extensive laryngeal diphtheria does 
not necessarily descend into the trachea, although he 
overestimates the numerical frequency of this exclusive 
localization. Trendelenburg infected the trachea of a rab- 
bit with diphtheritic deposits which he had removed from 
the pharynx and tonsils, in the tissues of which they were 
deeply and firmly imbedded. The new deposits, however, 
did not take so deep and firm a hold on the tissues as the 
original ones, but adhered lightly to the mucous mem- 
brane of the trachea to which they had been transplanted. 

It must not be forgotten that the character of the 
mucous membrane varies with the locality. Its different 
elements, as the epithelium, basement membrane, connec- 
tive tissue mingled with elastic fibres, blood-vessels, 
nerves from the cerebro-spinal and sympathetic systems, 
and frequently with spindle cells, the papillas and ducts 



122 A TREATISE ON DIPHTHERIA. 

of numberless glands, all influence the pathological pro- 
cess going on upon the surface. 

THE MUCOUS MEMBRANE OF THE MOUTH 

contains a large number of elastic fibres mixed with cel- 
lular tissue and covered by a thick coat of pavement 
epithelium, whose uppermost layer contains flat cells, the 
second a larger quantity of polygonal cells, and the lowest 
oval ones which assume a perpendicular relation to the 
mucous membrane. From the mucous membrane a num- 
ber of papillae extend into the epithelium, and in this re- 
spect resemble the papillae of the skin. Acinous mucipar- 
ous glands are frequent, and most numerous in the anterior 
aspect of the soft palate. Lymph vessels are very numer- 
ous in the lips, tongue, uvula, soft palate, anterior and 
posterior pillars of the soft palate, and cheeks. The 
uvula contains so many that, if they be injected, its circum- 
ference is increased two or three fold. They empty into 
the deep facial glands to which they communicate the in- 
fection in diphtheria. The lymphatics of the tongue are 
in intimate connection with the upper layer of the deep 
cervical glands ; those of the floor of the mouth and many 
from the tongue, with the submaxillary glands. The 
efferent vessels empty their contents into the superior 
jugular glands, in the trigonum cervicale superius, and 
finally into the fifteen or twenty inferior jugular (or supra- 
clavicular) glands, which with numerous anastomoses 
form the jugular lymphatic plexus. The tonsils are con- 
glomerations of an indefinite number of glandular bodies, 
each of which has a thick capsule which is of irregular 
shape, and consists of connective tissue lined by mucous 
membrane and pavement epithelium. The connective 
tissue contains a number of closed follicles, each inclos- 
ing numerous lymph-corpuscles. These follicles have been 
considered identical with, or analogous to, the lymphatic 
glands ; this assumption is purely problematical, since it 
has not been possible, thus far, to verify the existence of 



ANATOMICAL APPEARANCES. 1 23 

afferent or efferent ducts. The practical deduction from 
this is, that the tonsils have little or no connection with 
the lymphatic system. The number of blood-vessels in 
the normal tonsil is not large, and it becomes greatly 
diminished when that organ has been the seat of repeated 
chronic inflammations. It is in these very cases of chronic 
inflammation and enlargement of the tonsils, with con- 
siderable hypertrophy of the connective tissue, that diph- 
theritic attacks are most frequently observed, especially, 
of course, when a fresh irritation has given rise to inflam- 
mation and an cedematous enlargement. 

THE MUCOUS MEMBRANE OF THE NASAL CAVITIES 

is of varying degrees of thickness ; it consists of connec- 
tive-tissue fibres with numerous nuclei, is free from elastic 
fibres, but is supplied with a large number of nerves, and 
an abundance of blood-vessels ; the Schneiderian mem- 
brane possesses in fact a larger number of blood-ves- 
sels than most of the other mucous membranes. It is, 
therefore, with its submucous tissue, the seat of frequent 
swellings and hemorrhages, as well in diseases of distant 
organs which give rise to venous stagnation, as from the 
slightest local provocation. The inner surface of the car- 
tilaginous portion is lined with pavement epithelium ; the 
lower region of the real nasal cavities, the so-called 
respiratory portion, through its whole length supplied with 
branches of the trigeminus, is lined with cylindrical epithe- 
lium, and contains a large number of mucous glands. The 
upper or so-called olfactory portion is lined with ciliated 
epithelium, and is supplied, according to Todd and Bow- 
man, with long, straight tubular glands. According to 
Max Schultze, certain of the epithelial cells, particularly 
those belonging to the layer of oval, bipolar ones, are in 
connection with the terminal ends of the olfactory nerves. 
They have been designated as olfactory cells. In the last- 
named portion of the nasal cavities the lymphatics are but 
poorly developed, while in the inferior portion they are 



124 A TREATISE ON DIPHTHERIA. 

very numerous ; all their openings communicate directly 
with the deep facial and posterior submaxillary glands. 
Thus it can be readily understood why the slightest irri- 
tation, by a nasal catarrh for instance, in a child produces 
a temporary or permanent swelling of the glands. 

THE EPIGLOTTIS 

carries pavement-epithelium of 0.2 mm. in thickness on its 
anterior superior surface, that on its posterior surface being 
from 0.06 to o. 1 mm. in thickness. The superficial layer 
consists of spheroidal or polygonal cells, the deeper, of 
cylindrical cells, is arranged perpendicularly to the surface. 
Near the attached extremity of the epiglottis, the polygo- 
nal cells disappear, the cylindrical occupy the surface, and 
are furnished with cilia 0.005 mm. in thickness. Beneath 
these there are round and oval cells in considerable num- 
ber, so that the whole epithelial coating has a thickness of 
0.510 mm. Ciliated epithelium is also found on the false 
vocal cords and in the ventricles of the larynx. Polygonal 
pavement-epithelium forms the covering of the posterior 
surface of the pharynx, of the ary-epiglottidean folds, 
where the mucous membrane possesses, in addition, a heavy 
and lax submucous tissue, and of the true vocal cords. 
As one approaches the laryngeal ventricles and trachea, 
the previous coating is replaced by delicate ciliated epi- 
thelium. The mucous membrane in the neighborhood of 
the laryngeal ventricles is itself very loosely attached, ex- 
ceedingly thin, and frequently thrown into folds on the 
true vocal cords. Acinous glands are here very abundant, 
being fifteen to twenty to the square cm., and arranged 
lengthwise. Around the ventricles they are very numer- 
ous, and their outlets are lined with cylindrical, rarely with 
ciliated epithelium. The true vocal cords are not supplied 
with glands of any kind. 

The acinous glands have no lymphatics leading into 
them, but the latter may be seen in other parts of the mu- 
cous membrane of the larynx and submucous tissue. In 



ANATOMICAL APPEARANCES. 1 25 

fact, they are both large and numerous, and have the gen- 
eral character of lymphatics, the endothelium in particular. 
In the epiglottis of the new-born, they form but a single 
layer, in the larynx and trachea two layers, and in certain 
parts which are covered by a considerable amount of sub- 
mucous tissue, there are even three layers. In the inner- 
most, the lymphatics are arranged perpendicularly to the 
surface ; in the outer, horizontally. 

Conglomerate glands, frequently found by Verson in 
the cat, and invariably in the laryngeal ventricles of the 
dog, are seen in but few parts of the human air-passages. 
The exceptions, such as the vestibule of the larynx, the bor- 
ders of the ary-epiglottidean folds, and the posterior surface 
of the epiglottis, which were noted by Luschka, rather 
tend to emphasize the general rule than to disprove it. 

THE MUCOUS MEMBRANE OF THE TRACHEA AND 

BRONCHI 

contains more elastic than fibrous tissue, a moderate 
amount of lymphatic vessels, no lymphatic glands, an 
abundance of mucous glands, and is freely supplied with 
ciliated epithelium. 

The following table will serve as a resume of the above- 
described anatomical characteristics. 

Among all the tissues and organs thus far spoken of, 
the elastic, which is an important element in the formation 
of connective tissue, is least affected by chemical or organic 
influences. It does not become glutinous by boiling, 
and is not decomposed by water, acetic acid, alcohol, the 
gastric juice, or moderate heat. It is dense, firm, and hard, 
and possesses a degree of elasticity that no other tissue 
has attained in a normal condition. It has but few blood- 
vessels, no nerves, few lymphatics, and undergoes a very 
slow metamorphosis. When injured, it is never repro- 
duced, its reparative process results in the formation of a 
fibrous cicatrix. Now, elastic tissue is not present in the 
mucous membrane of the nose, it is so to a considerable 



126 



A TREATISE ON DIPHTHERIA. 



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ANATOMICAL APPEARANCES. 1 27 

amount in the buccal cavity, very abundant in the walls of 
the lymph-follicles of the tonsils, and so prominent an ele- 
ment in the trachea that the fibrous tissue is relatively tri- 
fling. The influence of the anatomical condition on the 
diphtheritic process must be very marked. It can easily 
be demonstrated that where the elastic tissue is present 
to a large amount, an antagonism to diphtheritic impreg- 
nation is maintained for a long time, but when it is obliged 
to yield, there is a corresponding resistance to recovery. 

It is the pavement-epithelium, according to Wagner, 
which gives the first foot-hold to diphtheritic membrane. 
Where it is most abundant, the diphtheritic poison can 
most easily settle and develop. Thus it is that the tonsils, 
not from their prominent situation alone, but from the 
character of their surface also, are favorable to the 
reception and further development of the infection, and 
their elastic and connective fibres, when once affected, are 
apt to harbor the process a long time. Ciliated epithe- 
lium, on the other hand, is not so liable to be affected. It 
occupies a higher rank in the scale of animal formation, 
has a more complex function and a greater power of 
resistance. 

The presence of a large number of mucous glands im- 
pedes, as a rule, by the presence of the normal secretion, 
an extensive destructive action upon the tissues. The 
secreted mucus assists in removing epithelial masses, and 
even fibrinous exudations, from the surface. The tissues 
themselves do not take an active or prominent part in the 
process ; the serum of the mucus penetrates the parts 
which are the seat of morbid deposits, and tends to pre- 
dispose them toward maceration, and the mucous secre- 
tion raises mechanically the superjacent deposits from 
their bed. Thus it is that the deposits in the respiratory 
portion of the nasal cavities are frequently cast off through 
the nostrils, probably because they have been produced 
in excess, and in a similar manner, the membranes that 
have formed in the trachea are ejected in a semi-solid con- 



128 A TREATISE ON DIPHTHERIA. 

dition through a newly-made tracheotomic outlet. The 
large number of mucous glands in the larynx and trachea 
is unquestionably the reason why the lymphatic vessels 
of the mucous membrane are not influenced by the over- 
lying loosened masses, and will not absorb ; hence laryng- 
eal and tracheal diphtheria have decidedly a local char 
acter, and are so frequently devoid of constitutional 
symptoms. 

THE VOCAL CORDS 

deserve especial notice. They form the borders of the 
narrowest aperture of the air-passages. Foreign bodies, 
whether malignant or otherwise, are detained or retained 
by them. They are covered with pavement epithelium 
which, as has been remarked, is the principal resting and 
breeding place of the diphtheritic affection. They have 
no muciparous follicles, and few or no lymphatic vessels, 
and therefore if there is any part which is predisposed to 
diphtheritic infection it is certainly the vocal cords. 
Where the poison is insufficient for general infection, it is 
at times capable of still producing local phenomena. 
Where an epidemic of diphtheria has died out, a local 
diphtheritic infection can still take place, and individual 
cases occur now and then with an almost insignificant 
power of infection. Such occurrences take place for years 
or decades, and give rise to the so-called sporadic mem- 
branous croup, in the same way as we have for years 
heard of an occasional case of sporadic cholera or of a few 
cases of small-pox. There may not be sufficient infectious 
material to act on the blood, larynx, or pharynx, but just 
enough to gain a foothold on the prominent vocal cords 
with their pavement epithelium. 

On the other hand, the absence of acinous glands on the 
vocal cords must serve to a certain degree as a guard 
against the disease. Dry, atrophic, smooth conditions of 
the mucous membrane of the fauces likewise tend to ward 
off an attack of diphtheria. A more or less moist or 



ANATOMICAL APPEARANCES. 1 29 

viscid condition of the surface is necessary in order that 
the poisonous material may cling thereto. The compara- 
tive dryness of the vocal cords, however, considered by 
the side of the perpetually moist and uneven surface of 
the pharynx, would not appear as favorable to the deposi- 
tion of foreign infectious elements. Thus there are cer- 
tain conditions predisposing to, others antagonizing in- 
fection. They demonstrate, however, why laryngeal 
croup is more frequent in winter than in summer, in direct 
proportion to the greater frequency of laryngeal catarrh 
in winter than in summer. Diphtheritic membranes on 
the vocal cords are not easily cast off, for there are no sub- 
jacent muciparous glands whose secretion could wash 
them away. No general infection can arise from them, 
for they have no lymphatic vessels which could serve as 
carriers of the poison ; furthermore, suffocation occurs 
too early to enable the few neighboring lymphatics to 
absorb and transport the poison elsewhere, in case the de- 
posits should finally become macerated. 

It strikes me that these anatomical and physiological 
considerations will help to throw light on the question of 
the mooted difference between "croup" and "diphtheria." 
The lymphatic and vascular systems must be looked upon 
as the most influential factors in the development and 
severity of the general phenomena in diphtheria. The 
absence of the lymphatics and the paucity of blood-ves- 
sels explain why diphtheria of the tonsils has so mild a 
character. The large number and size of, as well as the 
direct communication of the lymphatic ducts of the 
Schneiderian mucous membrane with the lymphatic glands 
of the neck accounts for the dangerous character of 
diphtheria of the nose. However, the direct infection, 
i. e., the absorption of the poison into the body, is not 
always dependent on the lymphatics, for they have occa- 
sionally neither enough time nor the opportunity to use 
their power. For instance, in those cases of diphtheria 
of the nose in which early and slight epistaxes occurred, 
9 



130 A TREATISE ON DIPHTHERIA. 

the poison appears to have been absorbed directly into 
the blood-vessels. Then we fail to observe the ordinary 
swelling of the neighboring glands of the neck, but the 
general symptoms are very rapidly developed. Usually, 
however, infection results through the lymphatics. The 
fluid contents of the tissues, or such particles or elements 
as are suspended therein, be they of a gaseous, chemical, 
or parasitic nature, are conducted to the lymphatic glands 
whose peripheric fascia propria serves as the first resting- 
place, for here' the lymphatic vessels subdivide, previous 
to penetrating the fascia and evacuating their contents 
into the lymph-spaces of the alveoli of the cortical sub- 
stance. As is well known, the latter are filled with lymph- 
corpuscles consisting of coarse, . granular protoplasm. 
From hence the lymph is carried off by delicate ves- 
sels into the substance of the glands. Their structure is 
the same as that of the cortical substance, with the excep- 
tion that they are less dense because of their containing 
less connective tissue and more and larger lymph spaces. 
All the infectious material that had entered the afferent 
channels and is small enough to be carried onward with 
the lymph and newly-suspended lymph corpuscles, is now 
introduced into the uninterrupted lymphatic and vas- 
cular currents, unless obstructed by a second series of 
lymphatic glands. All that which is as delicate as the 
lymph, and not larger in its microscopic proportions, is 
conveyed without interruption through the fascia propria 
into the reservoir of the cortical and medullary substances 
of the glands. There may be two conditions, however, 
which will serve to impede the current. In the first 
place, the foreign material may be present in too large an 
amount to circulate with ease ; the result will be stagna- 
tion and consequent irritation, either in the fascia propria 
or in the glandular substance. By pressure, the capillary 
circulation becomes interfered with, proliferation ensues, 
the circulating lymph mingles with the white corpuscles 
from the lymph spaces, and the result is an abscess in the 



ANATOMICAL .APPEARANCES. 131 

intra- or peri-glandular tissue. When this is not the case, 
the foreign material is retained in the interior of the fas- 
cias in the connective tissue or in the dilated lymphatic 
vessels of the cortical substance. Thus fluids injected 
into the cortical substance have been found collected 
in the external portions of the glands, where it was im- 
possible for them to be carried into the circulation. 
Hence the gland may serve as the receptacle of noxious 
elements which have circulated in the lymphatic current, 
with or without danger to the integrity of its tissues. In. 
this manner a second attack of diphtheria may often find 
its explanation in the absorption of stowed away poison ; 
syphilis also, and other poisons, may be stored in the 
gland, or if their presence prove irritating, give rise to 
speedy suppuration, and even elimination, provided the 
abscess be opened sufficiently and early. 

The glands may swell considerably, though the foreign 
matter be not present in excess, but of a very irritant 
character— this will occur where the poison is of a hetero- 
geneous nature — no matter whether the elements are of a 
chemical or a parasitic nature. The swelling may be very 
marked. In infection from cadaveric poison, the axillary 
glands may become fifty times their normal size, for it is 
they and not the cubital glands which form the first upward 
station of the greater number of lymphatic vessels of the 
fingers. 

The glands of the neck, too, may in diphtheria become 
enormously swollen within a few hours. Swelling to a 
certain degree always results when there has been an irri- 
tation of the lymphatic system. I have already referred 
to the irritation produced by a simple nasal or oral 
catarrh, resulting in a gradual swelling of the neighboring 
lymphatic glands. It is a positive fact that many a case 
of so-called scrofula, founded on an indolent swelling of 
the lymphatic glands, would find a ready explanation in 
the presence of a chronic nasal catarrh or of superficial 
erosions of the buccal mucous membrane. If the absorbed 



132 A TREATISE ON DIPHTHERIA. 

material be but little irritating, but in sufficient amount 
and extending over a longer period, a considerable mass 
may be taken into the circulation before they can give rise 
to a local swelling. If the materials are very minute and 
in moderate amount, they may traverse the lympha- 
tics for days and even weeks, and finally give rise to 
general infection rather than to a local disorder. This 
will ensue when elimination is less rapid than absorption. 
In this way an infectious poison, whose elements, organic 
or not, may be ten or twenty times smaller than the 
lymph-corpuscles — if it be feasible to calculate their size 
or predict their immediate changes — may stagnate in 
the smallest blood-vessels, proliferate rapidly, and then 
travel onward, or give rise to changes in the red blood- 
cells and leukocytes of the smallest vessels, and lead to de- 
posits of a purulent, septic, and gangrenous character, and 
a disintegration of the normal tissues on a large scale, be- 
fore local symptoms can be diagnosticated. Indeed, we 
often find that the apparently mildest cases of diphtheria 
eventually exhibit the most unpleasant symptoms. Sudden 
collapse and death are usually noticed in the apparently 
mild cases, and thus we are rarely in a position to say at 
the outset without hesitation (not even when nothing is 
perceptible except a circumscribed local diphtheria of 
the tonsils) that the individual case will prove mild or 
severe, that it will be short-lived or followed by succes- 
sive ailments. 

SUMMARY. 

The membrane, or the granular infiltration, are charac- 
teristic of diphtheria. Its contents are, more or less, 
fibrin, changed epithelium, blood, mucus, and pus. The 
main changes take place in the pavement epithelium, ac- 
cording to E. Wagner. The epithelium is as rapidly re- 
newed as changed. The views of histologists do not, 
however, agree about the nature or the importance of the 
epithelial transformations. The doctrine that the diph- 



ANATOMICAL APPEARANCES. 1 33 

theritic process is caused, excited, or aided by bacteria is 
either sustained or denied by many. The membranes pro- 
duced by artificial irritation are considered by some iden- 
tical with, by others to differ from, the genuine diphtheritic 
product. The former view is held by the foremost clini- 
cians. 

Most organs are liable to participate in the diphtheritic 
process, the blood (thin, black), the heart (granular, fatty, 
hemorrhagic, thrombotic, endocarditic), the lungs (several 
forms of inflammation, infarctus, oedema, emphysema), the 
spleen and sometimes the liver (large, hypersemic, soft), 
the kidneys (congested, nephritic), the muscles (ecchymo- 
tic, degenerated, atrophic), the glands (swelled, ecchymo- 
tic, gangrenous, suppurating), the intestine and other 
viscera. 

The, several forms of diphtheria have a peculiar predi- 
lection for certain organs or part of organs. This pre- 
dilection depends on the character of the surface and its 
epithelium. The greater or less amount of elastic tissue, 
the number or absence of muciparous glands and of lymph 
vessels, the nature of the epithelium (pavement, ciliated, 
or fimbriated), determine the character of the membrane 
in the different locations. Copious secretion of mucus in- 
duces early maceration. 

The vocal cords are apt to serve as resting-places for 
the diphtheritic poison, but constitutional infection is pre- 
vented by the absence of lymphatics, and rapid maceration 
by that of muciparous glands. 

Nasal diphtheria is apt to be very fatal by the immense 
net of lymphatics in the Schneiderian membrane, or by 
direct absorption into the superficial blood-vessels. 

Lymphatic glands swell very considerably, but suppu- 
rate but rarely. They may serve as depots from which re- 
absorption and relapses may take place. 



134 A TREATISE ON DIPHTHERIA. 



CHAPTER VII. 

DIAGNOSIS. 

The characteristic sign of diphtheria is the membrane, 
with more or less injection of the surrounding parts. In 
regard to this more or less injection, I will say that 
pharyngeal congestion, when it is uniform, may or may 
not point to imminent diphtheria. When it is local, con- 
fined to one side mainly, it is either traumatic or diph- 
theritic. White spots which are easily washed away, or 
can be removed with a brush, or squeezed out of the fol- 
licles of the tonsils, into which a probe can be introduced 
sometimes to the depth of one-half inch, soon announce 
their true character, either a simple catarrhal secretion or 
the effects of suppuration. Even though the superficial de- 
posit contain oidium or leptothrix in considerable numbers, 
it can easily be removed ; I have only known the totally in- 
experienced to mistake muguet of the mouth for diphtheria. 
In the larynx, muguet is, moreover, very rare indeed, and 
always circumscribed, mainly on the true vocal cords. 
The gray discoloration of superficial follicular ulcerations, 
as observed in the ordinary form of stomatitis follicularis, 
can hardly fail to be recognized. Such patches are very 
numerous in the fauces and on the lips and cheeks, never 
on the gums, except in ulcerous stomatitis which is not 
follicular. They are accompanied, too, by vesicles con- 
taining more or less serum, which have not yet ruptured. 
It must be remembered, however, that the mucous mem- 
brane, when deprived of its superficial covering, is liable 
during an epidemic of diphtheria to become infected, like 
every other wound. I have seen cases in which stomati- 
tis and diphtheria existed side by side, the latter having 



DIAGNOSIS. 135 

invaded the exposed surfaces resulting from the former. 
The examination of the entire throat is not always easy. 
Very young children vomit frequently and persistently 
before the whole surface is exposed to view, and not in- 
frequently, repeated examination with the spatula is ab- 
solutely necessary. In general, however, the slight 
attempts at vomiting suffice to cause a great part of the 
swollen posterior portion of the tonsil to revolve into 
view. I have heard that the pale surface of old hyper- 
plastic tonsils has been mistaken for diphtheria ; I merely 
mention this fact to stigmatize so gross an error. When 
a discoloration happens to be the result of a deposited 
flake of mucous, a drink of water will remove it. 

Fever is not always a prominent symptom ; in fact at 
times it is necessary to take the rectal temperature in 
order to discover an elevation ; as a rule, simple diphthe- 
ria of the tonsils is accompanied by very little fever. 
Still there are plenty of exceptions. But the differences of 
temperature are not more striking than in most other 
infectious diseases, whose either mild or severe invasion 
may offer an obstacle to immediate diagnosis. As the 
height of the fever does not absolutely determine or even 
indicate the character of the subsequent course of the 
disease, but little importance is to be attached to the tem- 
perature, unless there be a very marked elevation. A 
sudden rise frequently occurs with lymphadenitis. 

High fever in the beginning may render the diagnosis 
difficult or postpone it. A girl of fifteen years, who had 
suffered from intermittent fever a great deal previously, 
was taken sick with a chill, with flushed face and throat 
after, and a temperature of 106 . This attack also was 
referred to the influence of malaria poisoning, the single at- 
tacks of which had generally lasted from twelve to sixteen 
hours. The next morning her temperature was still 104 . 
The diagnosis of malaria was dropped. There was a slight 
patch on one of her tonsils. That very evening her 
temperature was still the same, and some little albumen in 



136 A TREATISE ON DIPHTHERIA. 

her urine. A great deal of albumen the day after, and 
the third day but little albumen, copious urine, and a tem- 
perature of ioo%° (rectum). 

The absence of lymphadenitis does not nullify the 
diagnosis of diphtheria, for when the tonsils are affected 
by the disease, there is frequently little or no swelling of 
the neighboring glands. The swelling of the glands en- 
ables us to locate the affection in a mucous membrane 
richly endowed with lymphatic vessels. It is very 
marked when the nose is affected. A few hours' duration 
of nasal diphtheria suffices for the development of a 
severe lymphadenitis, especially at the angles of the jaw. 
When the latter condition is found to exist, the throat 
should be examined with the idea of finding a membrane 
extending upward ; nasal diphtheria is very liable to com- 
plicate an affection of the uvula and arches of the palate. 
The membrane cannot well be seen by looking through 
the nostrils ; highly serviceable for this purpose is a 
very short, broad rhinoscope reaching upward to the 
bony structure of the nose. However, nasal diph- 
theria may frequently be diagnosticated some days be- 
fore the membrane becomes visible, by the rapid develop- 
ment of lymphadenitis ; this may be done even where the 
sweetish, musty odor of certain forms of diphtheria is ab- 
sent. Yet nasal diphtheria may occur without much 
lymphadenitis ; as, for instance, when the blood-vessels 
are very numerous and superficial, and thereby give rise to 
slight hemorrhages at the very beginning of the sickness. 
In such cases the lymphatic vessels are little, if at all, 
required to transmit the poison, the open blood-vessels 
replacing them in the function of absorbing. Naturally 
there are cases in which an ocular examination is not im- 
mediately or even at any time satisfactory. In the jour- 
nals we read of brilliant results of rhinoscopic and 
laryngoscopic examination ; in practice we see but few ; 
the patients are less inclined or in the proper condition to 
submit thereto, than the observer. This holds good 



DIAGNOSIS. 137 

especially for the dyspnoea accompanying laryngeal diph- 
theria where the diagnosis may be doubtful, when no 
membrane can be detected in the fauces ; even if mem- 
brane be observed there, symptoms of suffocation may 
still arise from a laryngeal stenosis independent of mem- 
branous deposits in the larynx. If aphonia and difficulty 
of both inspiration and expiration be present at the same 
time, there is certainly membranous occlusion. If aphonia 
appear late, or even toward the very last, and only inspir- 
ation be impeded while expiration is comparatively free, 
there is an cedematous saturation of the ary-epiglottidean 
folds and its copious sub-mucous tissue, and consequently of 
the posterior attachment of the vocal cords. Such a condi- 
tion is not at all uncommon — whereas, a general oedema 
glottidis in connection with diphtheria is of exceedingly 
rare occurrence — and has forced me to tracheotomize many 
times ; but again, a comprehension of the true condition, 
where it occured in not very severe cases, has on several 
occasions enabled me to avoid an operation. This local 
oedema may sometimes be detected by palpation in the 
region of the swollen posterior wall of the pharynx. 

One of the diagnostic symptoms of membranous laryn- 
gitis, believed in and referred to by Kronlein, does not 
exist, viz., the swelling of lymphatic glands, which in his 
opinion is pathognomonic. Not only is that not the case, 
but what I said above of the absence or scarcity of 
lymphatics and muciparous glands of the vocal cords 
and their neighborhood renders the absence of lymphatic 
swellings a necessity, provided the latter do not depend 
on complicating diphtheria in other localities. In uncom- 
plicated diphtheritic laryngitis I expect no lymphadenitis. 
The character of the laryngeal membrane does not depend 
at all on the condition of the pharynx. The latter may have 
membranes of any description or consistency, without be- 
ing able to determine the condition of the larynx. I lay 
stress on this fact because no less a writer than Kronlein 
believes that where there is but little or no membrane 



138 A TREATISE ON DIPHTHERIA. 

in the pharynx, that in the larynx is rather loose and 
movable. 

One of the pathognomonic symptoms of diphtheritic 
laryngitis, " membranous croup," is the relative absence of 
fever. Catarrhal laryngitis, pseudo-croup, is a feverish 
disease. A sudden attack of " croup " with high temper- 
ature — provided there is no pharyngeal or other diph- 
theria present — yields a good prognosis ; without much 
fever, a very doubtful one. If I had but words strong 
enough to impress that fact upon the minds of my 
readers, for this is the very diagnostic point against which 
most sins are committed. A boy of four years, F. M., in 
the practice of Dr. Teller, had in December, 1877, an attack 
of tonsillar diphtheria with very little fever ; after a few 
days, his diphtheria being better, fever set in (io4°-io5°) 
with hoarseness and some stenosis. It proved a temporary 
affair of short duration (catarrhal laryngitis), of which he 
soon got well. On January 3d, 1878, moderate laryngeal 
stenosis, hoarseness ; supra-clavicular and diaphragmatic 
exertion not great ; inspiration a little prolonged, with al- 
most a normal pulse ; a slight diphtheritic spot on lower 
lip, and the end of the tongue, and a temperature (rectal) 
of 101 . Diagnosis: membranous laryngitis, which was 
verified by the experience of the following days and 
necessitated tracheotomy. 

Another boy, three and a half years old, H., a patient of 
Dr. Obbarius, exhibited at 6.30 p.m., on November 2d, 1877, 
the following symptoms : Slight redness of fauces, hoarse- 
ness, difficulty of both inspiration and expiration, pulse 
rather normal. No elevation of temperature. Diagnosis : 
laryngeal diphtheria (" membranous croup "). At 2 A.M., 
November 3d, tracheotomy had to be performed hurriedly, 
while the temperature was 99^ (rectal), pulse 96 imme- 
diately after the operation, which produced quantities of 
false membrane. 

Membranous deposits inside the larynx are characterized 
by the above symptoms ; also the paralysis of the vocal 



DIAGNOSIS. 



139 



cords produced by ary-epiglottic oedema, posteriorly, by the 
symptoms enumerated above. Now and then there is a com- 
plication of both, now and then the symptoms are not well 
pronounced. Sometimes, when there are membranes on 
the tonsils, it may be of importance to watch the posterior 
aspect of the pharynx. When it is not swelled, not cede- 
matous, the stenosis is probably of a membranous char- 
acter. When it is cedematous, the probability is in favor 
of oedema about the insertion of the vocal cords. 

L. Fleischmann has placed the principal real or alleged 
symptoms of " croup " and diphtheria side by side in the 
following manner : 



Croup. 

Not contagious. 

True pseudo-membrane lying 
on the surface of the mucous 
membrane, from which it can 
be removed. 

Most in children. 

Most frequently affects the mu- 
cous membrane of the air- 
passages. 



Paralysis never occurs. 

No infection of the blood, 
with corresponding symp- 
toms depending thereon. 

Swelling of the glands, but al- 
most never suppuration of 
fcetid character. 

Begins as a catarrh that follows 
immediately after infection. 



Diphtheria. 

Contagious. 

Never a true croup-membrane, 
but deposits consisting of 
degenerated and exfoliated 
epithelium, fungi, and detri- 
tus. 

Occurs alike at all ages. 

" Multilocular invasion" fre- 
quently, the fauces, nose, 
genitals, intestines, and the 
skin being affected simulta- 
neously. 

Even in mild cases severe ner- 
vous disturbances. 

Infection of the blood and fat- 
ty degeneration of the 
striped muscular tissue, es- 
pecially that of the heart. 

Suppuration of the glands of 
frequent occurrence. 

Has a period of incubation and 
prodromi. 



140 



A TREATISE ON DIPHTHERIA. 



Croup. 

Croup may run its course with- 
out diphtheria. 



Not inoculable. 



Diphtheria. 

Diphtheria may run its course 
without croup, and invade 
other parts beside mucous 
membranes. 

Inoculable. 



J. Solis Cohen likewise tabulates the clinical differences 
between the two in a concise form, after acknowledging 
that there is no actual anatomical distinction between 
croup and diphtheria, either in the morbid products or 
the subjacent mucous membrane. His parallel is as fol- 
lows : 



Croup. 

Not specific in its origin. 
Never contagious. 
Not inoculable. 
Not adynamic. 
Usually sporadic. 

Rarely attacks adults. 

Always accompanied by an 
exudation. 

Only fatal by physical obstruc- 
tion to respiration. 

No weikening of the heart's 
action. 

Pulse frequently strong and 
hard. 

Respiration accelerated in pro- 
portion to the pulse, rarely 
less than i : 4. 

Rarely albumen in the urine. 

No secondary paralysis. 
Tolerates antiphlogistics. 

Rarely occurs more than once 
in the same person. 



Diphtheria. 

Specific. 

Frequently contagious. 

Inoculable. 

Adynamic. 

Generally endemic or epi- 
demic. 

Frequently attacks adults. 

Occasionally no exudation oc- 
curs. 

Often fatal without the least 
impediment to respiration. 

Marked weakening of heart's 
action. 

Pulse never strong and hard, 
even though rapid and full. 

Respiration not accelerated, 
usually less than 1 : 4. 

Albumen frequently present 
in the urine. 

Secondary paralysis frequent. 

Does not tolerate antiphlogis- 
tics. 

Frequent relapses. 



DIAGNOSIS. 141 

I gladly devote some space to these attempts at simpli- 
fication and explanation, in order to demonstrate to the 
reader the errors or exaggerations contained therein. To 
discuss the individual points separately would certainly be 
superfluous, after the consideration of the subject in which 
the reader has thus far accompanied me. These tabulated 
comparisons are not even convenient. Aside from the 
positive errors which they contain, hardly a single case 
of either " croup " or " diphtheria " could be appropriately 
placed beneath either head. Conditions which are de- 
pendent upon each other and which even clinically blend 
into each other continually, of which one indeed (croup) 
is recognized at last as a purely clinical term (unless the 
term croup be only applied to pseudo-membranous steno- 
sis), cannot be arbitrarily tabulated. 

To the above differential symptoms, Lyon (Trans. Conn. 
St. Med. Soc.) adds the following : 

Croup. Diphtheria. 

Pseudo-membranes of the skin Pssudo-membranes of the skin 
never observed. occasionally observed. 

Generally in cold weather. Is little influenced by weather 

or season. 

The larynx the principal seat The principal seat of the dis- 
of the disease. ease above the larynx. 

The first distinction does not exist, as any one knows 
who observed croup beyond its suffocative symptoms. 
Tracheotomy wounds, though carefully joined, fre- 
quently become diphtheritic within twenty-four hours, 
and from thence I have seen an extension of the process 
to the skin, and anywhere. Its author himself dulls the 
edge of the second distinction by his " generally " and 
"little," and in his anxiety for localization, he has in the 
third distinction simply reiterated that which has been 
assumed as a matter of convenience, namely, the designa- 
tion, by the term " croup," of the pseudo-membranous de- 
posits in the larynx, which give rise to stenosis. But, 



142 A TREATISE ON DIPHTHERIA. 

this is not a polemic book, and I therefore refer my read- 
ers to former pages. 

PRIMARY DIPHTHERIA OF THE TRACHEA AND ASCENDING 

CROUP 

does not occur frequently, yet it can be diagnosticated, 
and actual observation on the living and dead contradicts 
flatly the opinion of many writers whose opportunities 
may have been limited. Quite lately (Klebs, Handb. d. 
Pathol. Anat, VII., p. 283, 1880), Hans Eppinger risks the 
statement that "croup and diphtheria occur also in the 
trachea, but only when descending from the larynx." 
Without (occasionally with) an affection of the fauces, 
without general symptoms that would cause a feeling of 
anxiety to the parents, without more fever than one would 
expect in the slightest bronchial catarrh, without much dys- 
pnoea, and after symptoms of aslight bronchial or tracheal 
catarrh which have lasted a few hours or days, the little suf- 
ferers are most abruptly attacked by a stenosis of the 
larynx. Within an hour, or even less time, they become 
cyanotic ; tracheotomy affords but a slight temporary re- 
lief or none at all ; and the entire process occupies a very 
short space of time. Rarely is a large amount of mem- 
brane found in the larynx, but very much in the trachea 
and its larger ramifications. The disease began there, and 
without causing occlusion, because of the large size of the 
organ, ascended to the larynx, where it gave rise to a far 
more speedy death than is usually brought about by a 
descending croup. I have operated perhaps fifteen times 
in such cases, and no case, from the commencement of 
urgent symptoms to death, ever lasted more than a day, 
but many a few hours only. 

The secondary descending diphtheria of the trachea can 
only be recognized after tracheotomy has been performed. 
If an elastic catheter, feather, or probe be passed through 
the tube, the slightest contact with mucous membrane 
that is not covered by deposits will give rise to coughing. 



DIAGNOSIS. 143 

In proportion to the depth to which the process has de- 
scended, with a corresponding deposit of membrane, will 
this effect become less noticeable. By degrees the irrita- 
tion may be applied one or two inches and more below 
the inferior extremity of the tube, without producing any 
reflex phenomena. The approach of new symptoms of 
suffocation (which do not assume the fearfully violent 
character of laryngeal stenosis) and cyanosis, gradually 
usher in death which can in no wise be warded off. Al- 
though the duration of this scene must vary in different 
cases, yet I can point to a series of cases in which the 
interval between the performance of tracheotomy (which 
I undertook at the time deemed most proper by myself, 
and hence not late) and final death was sixty hours. 

PNEUMONIA 

accompanying the general process can be diagnosticated 
only if the larynx be not much affected. The latter, how- 
ever, is usually the case, and the laryngeal rales in such a 
case drown the auscultatory signs of pulmonary inflam- 
mation ; percussion, too, gives no satisfactory results, 
as the dulness may be caused as well by collapse of the 
lung-tissue as by infiltration. The same may be said of 
bronchitis and acute oedema which may be looked upon 
as the direct results of rarefaction of the air in the bronchi 
and alveoli of the lungs. Rapid increase of temperature, 
together with increased number of respirations, speak 
for pneumonia. 

Diphtheria of the vagina, of the CONJUNCTIVA, and of 
WOUNDS can only then be confounded with a simple puru- 
lent coating when an ocular examination is the only 
means at our command ; even then rarely. The same holds 
true for intestinal diphtheria. Large shreds and cylindri- 
cal moulds are not always formed of diphtheritic mem- 
brane, but sometimes of mere mucus compressed into that 
shape, with little epithelium and almost never with blood. 
Thus they are seen in chronic catarrh of the colon. In the 



144 A TREATISE ON DIPHTHERIA. 

dysenteric form of intestinal diphtheria the thrown off 
shreds are generally not large, and easily recognizable 
together with their accompanying symptoms. 

THE ERUPTION 

occurring in the course of diphtheria appears first on the 
warmer parts of the body, as the chest, neck, and abdomen ; 
occasionally, however, it covers the entire body, and is 
distinguished from the scarlatinous eruption in that the 
latter more frequently appears first on the hips and ex- 
tremities. Where it covers the entire body at once, in scar- 
latina, there are more severe general symptoms and higher 
fever than in diphtheria. In the former, the eruption 
lasts from five to six days ; in the latter, but a few days. 
Still mistakes may occur, as the intensity, extent, and dur- 
ation of the eruption in scarlatina may be very variable. 
In general, however — and this fact is of value in the 
diagnosis, to a certain degree — a marked scarlatinous 
eruption in the earliest period of the disease is accom- 
panied by a more characteristic erythema of the mouth 
and throat than in diphtheria, and with less diphtheritic 
deposits. These will, in scarlatina, appear after a few days 
as a rule, and not in the beginning. In diphtheria, the 
characteristic symptoms belonging to the tongue, redness, 
throwing off of the epithelium, papillar elevations, etc., 
are not so well marked. At times, however, the character 
of the desquamation only will decide the nature of the 
efflorescence. It appears, however, that in some epi- 
demics diphtheritic eruptions are but seldom observed, 
while in others they are more frequent. 
The appearance of 

ALBUMEN 

in the urine will serve as a valuable diagnostic point, some- 
times, between diphtheria and scarlatina. In the latter 
disease, it is rarely noticed in the first week ; it generally 
appears about the ninth or tenth day at the earliest, and 
it may be delayed until the twenty -fifth, even to the thirty- 



DIAGNOSIS. 145 

third in my experience. When it appears in the first 
week, it not infrequently presents the picture of a danger- 
ous form of general diffuse nephritis, which is apt to ter- 
minate lethally. In diphtheria, albumen is pretty sure to 
appear, if at all, within the first few days, neither the 
degree of fever nor other general symptoms affording an 
explanation of its presence. It is frequently found, and 
in large quantities too, for a day or two, apparently as a 
symptom of rapid elimination, in cases which set in with 
a high fever, which lasts but a short time, and gives way 
to almost complete apyrexia. 

Gangrene manifests itself in a destruction of the tissues, 
for instance of the vagina or cornea, and depends some- 
times on pressure by the impregnated surface ; or it 
occurs on such privileged localities as are adapted, from 
their coating of pavement epithelium, for deep inroads 
of the degenerative process. Still the genuine necrosis 
of the tissues occurs in other parts of the mouth besides the 
tonsils, but we must be careful not to declare any thick 
black briny masses at once to be gangrenous. Not infre- 
quently they are merely deposits which are easily removed. 
Genuine gangrenous masses readily bleed, either from the 
sharp corroded edges or from deep-seated vessels which 
have been injured. I have but rarely seen dangerous 
hemorrhages from grangrenous portions of the neck, and 
not many deaths therefrom. 

EPISTAXIS 

is not infrequently a formidable symptom. Its seat can 
sometimes be estimated by the facility with which, in dif- 
ferent postures, the blood makes its appearance in the 
throat. 

DIPHTHERITIC PARALYSIS 

exhibits certain peculiarities which facilitate diagnosis. 

The latter presents no difficulties for the practitioner who 

has witnessed the entire course of the disease and sees 
10 



I46 A TREATISE ON DIPHTHERIA. 

paralysis appear during convalescence. It becomes all 
the more easy when the soft palate is the first to be at- 
tacked, and is gradually followed by the implication of 
other parts. But in those cases where the diphtheritic 
process was not observed, and the soft palate was not 
affected or became so only later, the diagnosis will be 
more difficult, and may even be involved in utter dark- 
ness. The knowledge of the fact that diphtheria has 
pre-existed may arouse suspicion and guide the physician 
to a proper appreciation of the case. But it is necessary 
carefully to weigh the accompanying circumstances. A 
migrating paralysis of mixed character, like the diph- 
theritic, may be either peripheric or central. It is impor- 
tant to determine this point in the first place. Severe 
central lesions, whether of diphtheritic or other origin, 
will invariably present a certain clinical picture. Diffi- 
culties arise only when the question of multiple lesions of 
a different character, such as hemorrhages, sclerosis, can 
be raised at all. The more frequent, if not the constant, 
form of diphtheritic paralysis is the peripheric ; it runs 
a precisely opposite course to that which is described 
by some authors. It is not the assumed regularity, 
but just the remarkable irregularity and wavering char- 
acter of the paralysis, together with a capriciousness of the 
symptoms and of the affected organs or parts thereof, 
which are especially characteristic of the disease. 

As a general thing, the paralytic symptoms commence 
in the soft palate, and pass to the ciliary nerves after 
(mostly bilaterally). But the reverse may take place. The 
symptoms, when the patient does not get well soon, may 
extend over months, or rather, one will be replaced by 
another. Beside the above mentioned, there may be stra- 
bismus, general debility of the muscular system, local 
paralysis, atrophy of single muscles, atrophy of skin, and 
nutritive disorder with alopecia, disorder of sensibility, 
not always of a subjective character only, dyspnoea from 
either degeneration of heart or paralysis of respiratory 



DIAGNOSIS. 147 

muscles, irregular behavior under the influence of faradic 
(diminished) and galvanic (normal, sometimes increased, 
diminished after a while) currents. All the time, how- 
ever, the sphincters are intact (with very rare exceptions) 
as in the amyotrophic or peripheric paralysis of children. 

SUMMARY. 

Diphtheria is characterized by its membrane. The 
diagnosis from muguet is easy. Complications with folli- 
cular stomatitis are of occasional occurrence. Follicular 
inflammation of the tonsils is recognized by its local char- 
acter, by the ready removal of the deposits, and the easy 
introduction of a probe into the follicle. The congestion 
in the diphtheritic pharynx is sometimes less pronounced 
than in catarrhal pharyngitis. In the latter the hyperae- 
mia is general, in the former it may be local. 

Fever is not always high. Sometimes the temperature 
is even low in very bad septic cases. High temperatures 
in the beginning are less frequent than, for instance, in 
scarlatina. Glandular swelling may be absent for many 
reasons. 

Nasal diphtheria has much glandular swelling ; may, in 
some distinct cases, have none at all. 

Diphtheritic laryngitis has less fever than catarrhal 
laryngitis, and when uncomplicated shows no glandular 
swelling. The character of the laryngeal membranes does 
not depend on the condition of the pharynx. Complete 
aphonia and uniform difficulty of inspiration and expira- 
tion indicates membranous obstruction; difficult inspira- 
tion with easier expiration and but partial hoarseness or 
almost clear voice indicates the presence of local oedema 
and consecutive paralysis of the vocal cords. 

Primary diphtheria of the trachea is difficult to diag- 
nosticate ; it is likely to exist when after apparently catar- 
rhal symptoms those of laryngeal stenosis occur very 
suddenly and fatally. The progress of the diphtheritic 
process downwards can be watched through the trache- 



148 A TREATISE ON DIPHTHERIA. 

otomy tube and estimated by the absence of irritability of 
the mucous membrane of the trachea. 

The diagnosis of pneumonia accompanying laryngeal 
diphtheria is not impossible. In the other forms of diph- 
theria it is recognized by its usual symptoms. 

The cutaneous eruption of diphtheria is usually distinct 
from scarlatinous eruptions, and the diagnosis easy in most 
cases. Albuminuria is mostly an early symptom, and dis- 
appears more readily than in scarlatina. 

Diphtheritic paralysis is recognized by the previous 
history of the disease, by the frequency of its starting 
from the pharynx, its irregular course, its mostly peri- 
pheric character, and the absence of symptoms belonging 
to bladder or rectum. It is mostly motory, sometimes 
sensory or sensitive. 



PROGNOSIS. 149 



CHAPTER VIII. 
PROGNOSIS. 

Trousseau once expressed his opinion that diphtheria 
was more dangerous than cholera, yellow fever, or the 
plague. He certainly said so under the influence of the 
impression conveyed by some of the worst septic cases 
we are apt to meet with. Fortunately the sad picture is 
greatly overdrawn. I have already, on some previous 
pages, alluded to the fact that the majority of cases are 
of a mild type, and that in many a season the ratio of mor- 
tality is but small. Many a year it was not higher than five 
per cent of all the cases. Ten per cent is certainly a high 
rate. Still, as far as each individual case is concerned, 
there is hardly a disease in which the prognosis is more 
uncertain than in diphtheria. Before the process has 
fully run its course, it is unjustifiable to consider the 
favorable termination secured ; even when it is completed, 
a relapse may occur, which again casts obscurity over the 
entire question. The general character of individual 
epidemics, now mild, now severe, permits, it is true, to 
rely to a certain extent on probabilities, but the physician 
will often enough be deceived, and more frequently, too, 
in mild than in bad cases. There is a certain class of 
cases in which the prognosis is absolutely unfavorable ; 
there is another class in which it appears favorable, and 
yet dangerous symptoms and a fatal termination ensue. 
In general, the prognosis is favorable when the affected 
surface is of small extent, and where such parts are the 
seat of disease as have little communication with the 
lymphatic system. To the latter class belongs simple 
diphtheria of the tonsils. Marked glandular swelling, 



150 A TREATISE ON DIPHTHERIA. 

particularly if arising suddenly, is always an uncomfortable 
sign, and calls for the utmost caution, especially if the 
region of the angles of the jaw be speedily and markedly 
infiltrated. This, as we have seen, is particularly apt to 
occur with nasal diphtheria, whether developed primarily, 
accompanied by a thin foetid discharge, or, as is more com- 
monly the case, secondarily from an affection of the pharynx 
and palate in the continuity of tissue. With the appropriate 
local disinfection, it is neither so absolutely dangerous as 
Oertel depicts it, nor so assuredly fatal as Roger but a few 
years ago taught in his clinique, or Kohts appears to believe 
(Gerhardt, Handb. d. Kinderkr., III., 2, p. 20, 1878), yet it is 
ever doubtful. With energetic treatment, most cases will 
get well. Diphtheria of wounds, complicating diphtheria 
of the pharynx, is always an unpleasant sign ; that of the 
mouth and angles of the mouth, associating itself with a 
previously existing diphtheria, having an indolent course, 
and producing rather a deep impregnation of the tissues 
than a thick deposit, presents very disagreeable symptoms. 
Diphtheria of the larynx, whether it be of primary origin 
or the result of extension from the fauces, is nearly always 
fatal. In severe epidemics the mortality is 95 per cent. 
Tracheotomy, too, saves but few of those who take the 
disease at such a time. In fifty consecutive tracheoto- 
mies, from 1872 to 1874, I did not see one recovery. In 
the last few years, I have seen few good results. In 
average epidemics, tracheotomy will save 20 per cent. 
A pulse of 140 to 160, and high fever immediately after 
the operation, render the prognosis bad ; so does absence 
of complete relief after the operation. An almost normal 
temperature the day after the operation is an agreeable 
symptom, but does not exclude a downward extension of 
the diphtheritic process, and hence cannot be looked upon 
as assuring a favorable prognosis. A marked elevation 
of temperature occurs with a renewed attack of diphthe- 
ria, or a rapidly-appearing pneumonia, and is an unfavor- 
able symptom. A dry character of the respiratory mur- 



PROGNOSIS. 151 

mur, some time after tracheotomy, indicates the approach 
of death from descent of the membrane, within from 
twelve to twenty-four hours j* cyanosis likewise, whatever 
be its degree of intensity. Diphtheria of the trachea, 
which ascends to the larynx, is positively fatal. It has a 
rapid course, and tracheotomy only postpones the end 
for a little while if at all. The general health and strength 
of the little sufferer have no influence whatever. 

Thick, solid deposits need not of themselves render the 
prognosis so unfavorable as do septic and gangrenous 
forms. Even in the nose they are not of as serious import 
as the thin, putrid discharge. I have seen recovery ensue 
in cases where I was obliged to bore through the oc- 
cluded nasal cavities with probes and spoons. Foetid, 
putrid discharges are unfavorable, but in no wise fatal; 
conscientious disinfection accomplishes a great deal. 
Slight epistaxes indicate the possibility of rapid and un- 
doubted absorption through the blood-vessels ; but here, 
too, the final result depends on whether the disinfection 
be equally rapid and thorough. The same holds true for 
the sweetish, foetid odor of the breath, whether of the 
nose or mouth, which, on one hand, demonstrates the sig- 
nificance of the disease, while, on the other hand, it indi- 
cates the possibility of infection by the breath. 

The height of the fever is not in proportion to the dan- 
ger in the individual cases ; some have a favorable, some 
an unfavorable termination, without fever of any account. 
Simple catarrh of the pharynx and larynx frequently 
begin with a sudden and marked rise of temperature ; 

* R. W. Parker (Tracheotomy in Laryngeal Diphtheria, London, 1880) 
says: " The presence of membrane in the trachea in a fatal case of mem- 
branous laryngitis, after tracheotomy, must be regarded as evidence of the 
want of due care on the part of the surgeon in charge, just as much as would 
the presence of a piece of gut in the inguinal canal after herniotomy, or a 
calculus in the bladder after the operation of lithotomy." 

I do not hesitate to express my opinion that the gentleman will modify this 
" somewhat absolute dictum," as he calls it himself, after some more experi- 
ence. 



152 A TREATISE ON DIPHTHERIA. 

diphtheria in the same parts but rarely. There are cases, 
however, in which the height of the fever and the depos- 
ited membranes are in inverse proportion to each other. 
In these cases, the fever may subside rapidly, owing to a 
speedy elimination of the poison. Young children only are 
in danger of death from convulsions, or a rapid tissue 
degeneration. If the temperature rise suddenly after 
days of sickness, either a complication or a fatal termina- 
tion is to be apprehended. Yet, if we except laryngeal 
and tracheal diphtheria, there are as many deaths with com- 
paratively low, as with very high temperatures. Whether 
collapse has resulted rapidly or slowly, the patient dies 
often with low temperature. Thus a rapid elevation is 
hardly a more unfavorable sign than a rapid fall. The 
pulse, too, may be very variable. True, a small, rapid, 
and irregular pulse is always unpleasant, because it indi- 
cates a weakening of the cardiac function ; yet, as long as 
it retains an approximately normal relation to the fre- 
quency of respiration, a rapid pulse gives no cause for 
alarm. Moreover, the pulse is not always rapid when the 
strength gives way. It occasionally becomes slower, and 
sometimes very slow, and may then become a dangerous 
symptom. It seems to me highly probable that there is 
in such cases, as in certain forms of chronic fatty meta- 
morphosis of the heart, a degeneration of the cardiac gan- 
glia of the sympathetic. 

Every complication adds to the danger. Bronchitis and 
pneumonia are not infrequent ; yet I have seen cases of 
laryngeal diphtheria recover, in which I had suspected 
pneumonia before performing tracheotomy, and was en- 
abled to diagnosticate it after operating. Albuminuria in 
the early part of a diphtheritic attack (with high fever) 
is of little significance ; nephritis, later in the course of the 
disease, partakes of the character of scarlatinous nephritis ; 
cases of acute diffuse disease are fortunately infrequent, 
and the remainder are very submissive to treatment. The 
cases complicated with endocarditis, in my practice, 



PROGNOSIS. 153 

ended fatally. An early implication of the sensorium, not 
dependent on pressure upon the jugulars by greatly swol- 
len glands, is an unfavorable symptom. Purpura, with 
profuse hemorrhages and a livid hue of the skin, is omin- 
ous ; icteric discoloration, together with marked glandu- 
lar and periglandular tumefaction, is absolutely fatal. 
Calimani observed an epidemic in which he lost one hun- 
dred and fifteen cases out of two hundred. Before the 
diphtheritic eruption on the integuments took place, he 
often noticed a cyanotic discoloration and an offensive 
secretion of the last phalanx of the big toe, sometimes of 
other toes, or of the middle finger. All of those showing 
these symptoms died. A case of acute diphtheritic infec- 
tion with fatal termination, taking its course with the 
symptoms of pernicious icterus, was but lately recorded 
by Becker (Berl. klin. Woch., Nos. 30 and 31, 1880). 



154 A TREATISE ON DIPHTHERIA. 



CHAPTER IX. 

c 

TREATMENT. 

GENERAL REMARKS. 

Every case should be treated on general principles ; thus 
it is not possible to lay down a routine treatment for every 
individual case. High fever should be reduced by spong- 
ing and baths, quinine, and sodium salicylate ; collapse 
speedily treated, and severe reflex symptoms, as vomiting, 
etc., checked at once. Whether to employ for this pur- 
pose ether, wine, cognac, champagne, or coffee, must be 
decided by the physician in individual cases. The admi- 
nistration of the remedy, whether by mouth, by injection 
into the bowels, or subcutaneously, as I have employed 
cognac, ether, alcohol, and camphor dissolved in ether or 
alcohol, in some cases with decided and rapid success, 
must depend on the condition of the organs and on the 
urgency of the case. At all events, it may be stated that 
all the above remedies are frequently of no service be- 
cause they have been administered too late, and in too 
small doses, and hence we may infer that to obtain the 
proper results both from external and internal treatment, 
the remedy must be employed early and often, and in suf- 
ficient quantity. If I have ever had cause to feel con- 
tented with the results of treatment in diphtheria, it is 
owing to the fact that 1 did not lose time. Moreover, 
the nourishment of the patient is a matter of very great 
importance, and should not be neglected, and no medicines 
resorted to which are apt to derange the digestion of the 
patient. It is true that caution must be exercised in the 
food administered to febrile patients, but we must bear in 



TREATMENT. 1 55 

mind that, when the lymphatic vessels are kept empty, and 
no new and proper material is introduced into them, the 
absorption of locally existing poisonous substances is pro- 
portionately increased. 

I dwell particularly on the foregoing remarks for the 
reason that, in diphtheria, unlike certain diseases having a 
typical course and those of a simple inflammatory character, 
expectant treatment should not be indulged in. Oertel's 
advice, that when neither high fever nor complications are 
present we should quietly wait, and " act only when new and 
most alarming symptoms present themselves," is decidedly 
perilous. A mild invasion does not assure a mild course. 
Never has a " perhaps superfluous " tonic or stimulant done 
harm in diphtheria, but many a case had a sad termi- 
nation because of a sudden change in the character of the 
disease, putting the bright hopes of the physician to 
shame. Only the philosopher may be a passive spectator, 
the physician must be a guardian. When I again read, in 
the work of the same meritorious author, " that when in 
exceptional cases, in children and young people, death is 
imminent, not from suffocative symptoms in the larynx 
and trachea, but from septic disease and blood-poisoning, 
it is necessary to resort to powerful stimulants," it strikes 
me that he is frequently too dilatory with his remedies, 
and furthermore, that his experience concerning the ter- 
rible septic form of diphtheria, which is so frequently met 
with in some epidemics, must have been very limited at 
that time. In New York, during the past twenty years, 
for every death from diphtheritic laryngeal stenosis, there 
have been three from diphtheritic sepsis or exhaustion. 
To generalize from a few cases or years would be unsatis- 
factory. But few authors have displayed the unselfish- 
ness of Krieger, who, in his " Etiological Studies" (Strass- 
bourg, 1877), had repeated opportunity for observation, 
yet in his careful essay on the " Predisposition to Catarrh, 
Croup, and Diphtheritis," refers to the insufficiency of his 
own observations. 



156 A TREATISE ON DIPHTHERIA. 

When a modern writer (Ripley, Med. Rec, July 31st, 
1880) teaches that " diphtheria is a self-limited disease," 
" which runs its course from a few hours to weeks," and 
may " end in recovery, according to the character of the 
epidemic and idiosyncrasy of the patient, even without 
medicine," he certainly stretches the definition of a self- 
limited disease to undue proportion, while in regard to 
spontaneous recovery he states what may be said of any 
and every disease. His teaching that the only rational 
plan of treatment of diphtheria is a symptomatic one, is 
dangerous, because it is apt to seduce into the neglect of 
preventives, and of the timely resort to medication, to 
say the least. It is true that the results of no treatment 
cannot be uniformly successful, but at all events the indi- 
cations for causal treatment are commencing to be known 
at last. In that respect we have progressed somewhat be- 
yond the most thoughtful therapeutics of the disease, as 
developed in the course of the last century, and so well illus- 
trated by the " Tentamen medicum inaugurale de cynan- 
che maligna," by Thomas Wilson, Edinb., 1790. He says, 
p. 24 : " Cum hactenus nullum inventum est remedium 
quod contagionem in corpus receptam suffocare possit ; 
cum medicamenta pleraque quae putredinem corrigere 
dicuntur, corpus ejusque functiones manifesto roborant; 
et denique, cum hunc morbum comitantur virium prostra- 
tio, et, etiam ab initio, summa functionum debilitas, qualis 
evacuantia omnigena prohibet, indicationem curandi 
unicam, scil. debilitatis effectibus obviam ire, proponam. 
Hinc corporis conditioni obviam itur praecipue tonica et 
stimulantia administrando." (As no remedy has yet been 
found which can extinguish the contagion after it has 
been received into the body, as most medicines which 
have the reputation of correcting putrefaction, are robor- 
ants for the body and its functions, and lastly, as this 
disease is attended with great prostration and such debil- 
ity of functions as to preclude the use of all sorts of evacu- 
ants, I propose but this one indication for treatment, viz., 



TREATMENT. 1 57 

to meet the effects of debility. This is fulfilled by the 
administration of mainly tonics and stimulants.) 

While speaking of stimulants, I will say a lew words in 
regard to the dose to be given. There is more danger in 
diphtheria from giving too little than too much. When 
the pulse begins to be small and frequent, they must be 
administered at once. A three-year-old child can com- 
fortably take thirty to one hundred and fifty grammes of 
cognac, or one to five grammes of carbonate of ammonia, 
or a gramme of musk or camphor in twenty-four hours. 
In the septic form especially, the intoxicating action of 
alcohol is out of the question, the pulse becomes stronger 
and slower, and the patient enjoys rest. In those cases in 
which the pulse is slow, together with a weak heart's 
action, the dose can hardly be too large. The fear of a 
bold administration of stimulants will vanish, as does that 
of the use of large doses of opium in peritonitis, of quinine 
in pneumonia, or of iodide of potassium in meningitis or 
syphilis. 1 know that cases of young children with gen- 
eral sepsis commenced immediately to improve when 
their one hundred grammes of brandy was increased to 
four hundred in a day. 

The remarks I have made in reference to the general 
treatment of diphtheria naturally render superfluous a 
discussion of the value of abstraction of blood. To be 
sure, it could only be a question of local bleeding. For 
nobody would dare to resort to jugular venesection, as 
our predecessors did in the last century. It may be safely 
asserted of the latter that it has no influence on the pro- 
cess, but frequently increases the local swelling and makes 
the patient more anaemic. There is no case in which a 
resort to it would not be criminal. I can distinctly recall 
the time when bleeding and calomel formed the ground- 
work of the treatment. Until the year 1862, the death 
rate in Rupert, Vermont, from diphtheria was ninety per 
cent, according to the reports of the local physicians, and 
particularly of my pupil, Dr. Guild, who at that time 



158 A TREATISE ON DIPHTHERIA. 

finished his studies in New York and commenced practis- 
ing. When, in the same epidemic, bleeding and calomel 
were replaced by stimulants and iron, with the chlorate 
of potassium, ninety per cent recovered. 

That attention must be paid to the general condition, 
mainly during a retarded convalescence from previous 
sickness, is self-evident. Any complications, too, must be 
subjected to early treatment. Diarrhea must be men- 
tioned among these ; it reduces the patient's strength very 
quickly ; likewise, the early appearing nephritis which 
may suddenly end life. 

One important axiom must be borne in mind, namely, 
that prevention is more easy than cure. I do not refer 
simply to the removal of the healthy members of the 
family beyond the danger of infection, or to the isolation of 
the patient. If the latter becomes necessary, the first in- 
dication is his removal to the top floor of the house. 
There are, in addition, however, certain prophylactic 
measures which will prove valuable in the hands of every 
o-ood physician. It is necessary under all circumstances 
that the mouth and pharynx of every child be constantly 
kept in a healthy condition. Eruptions of the scalp must 
be treated at once, and glandular swellings of the neck 
caused to disappear. But lately some cases of laryn- 
geal diphtheria have been traced directly to the pres- 
ence of suppurating bronchial glands, with or without 
perforation (Weigert, in Virch. Arch., Vol. jj, p. 294, 
1879). The same rule applies to nasal and pharyn- 
geal catarrhs, the treatment of which should be be- 
gun in warm seasons, when general or local remedies 
yield better results. Enlarged tonsils should be resected, 
or, where that cannot be done, scraped out with Simon's 
spoon, at a time when no diphtheritic epidemic is raging. 
It is important that this take place at a time when, even 
though sporadic cases of diphtheria occur, the danger of 
infection is not great ; for, during the height of an epi- 
demic, every wound will give rise to general or local in- 



TREATMENT. 1 59 

fectlon. This holds true for wounds of any part of the 
bod}', as well as of the mouth. I therefore avoid an oper- 
ation at such a time, provided it can be postponed. 

In this connection 1 shall speak of a remedy which I 
class among the prophylactic agents, namely the chlorate 
of potassium, or the chlorate of sodium. I cannot say that I 
rely on either of these remedies as curative agents in 
diphtheria, and yet I employ them in almost every case. 
The reason lies in the fact that the chlorate is useful in 
most cases of stomatitis, and thereby acts as a preventive. 

There are very few cases of diphtheria which do not 
exhibit larger surfaces of either pharyngitis or stomatitis 
than of diphtheritic membrane. There are also a number 
of cases of stomatitis and pharyngitis, during every epi- 
demic of diphtheria, which must be referred to the epi- 
demic, sometimes as kindred diseases, and sometimes as 
introductory stages only, which, however, do not, or do 
not yet, show the characteristic symptoms of the disease. 

When, in i86o(Amer. Med. Times, Aug. nth and 18th), 
I wrote my first paper on diphtheria, I based it upon two 
hundred genuine cases, and at the same time enumerated 
one hundred and eighty-five cases of pharyngitis, which 
I considered to be brought on by epidemic influences, but 
which, the membrane being absent, could not be classified 
as bona fida cases of diphtheria. 

Such cases of pharyngitis and stomatitis, no matter 
whether influenced by an epidemic or not, furnish an 
indication for the use of chlorate of potassium. They 
will get well with this treatment alone. The cases of 
genuine diphtheria, complicated with a great deal of sto- 
matitis and pharyngitis, also indicate the use of chlorate 
of potassium ; not as a remedy for the diphtheria, but as a 
remedy for the accompanying catarrhal condition in the 
neighborhood of the diphtheritic exudation. For, it is a 
fact that, as long as the parts in the neighborhood of the 
diphtheritic exudation are in a healthy condition, there is 
but little danger of the disease spreading over the sur- 




l6o A TREATISE ON DIPHTHERIA. 

face. Whenever the neighboring surface is affected with 
catarrh, or inflammation, or injured, so that the epithelium 
is loose or thrown off, the diphtheritic exudation will spread 
within a very short time. Thus chlorate of potassium or 
sodium, the latter of which is more soluble and more easily 
digested than the former, will act as a preventive rather 
than as a curative remedy. Therefore it is that common 
cases of pharyngeal diphtheria will recover under this 
treatment alone, nothing else being required. 

The cases of diphtheria in which the exudation is lim- 
ited to the tonsils are by no means dangerous, for the 
lymphatic communication between the tonsils and the 
rest of the body is none at all, or very trifling. Thus no 
absorption into the circulation can take place from a ton- 
sillar diphtheritis alone. The surrounding stomatitis and 
pharyngitis will be favorably influenced by the administra- 
tion of chlorate of potassium or sodium, and thus the entire 
disease will run a favorable course, inasmuch as the ton- 
sillar exudation will be removed within three or six days. 
The surrounding portions of the mouth and fauces, mean- 
while, having been put into a tolerably healthy condition, 
the danger is passed. These are the cases which have 
given its reputation to chlorate of potassium as a remedy 
for diphtheria. 

The dose of chlorate of potassium for a child two or 
three years old should not be larger than half a drachm (2 
grammes) in twenty-four hours. A baby of one year or 
less should not take more than one scruple (ij^ grammes) 
a day. The dose for an adult should not be more than a 
drachm and one-half, or at most two drachms (6 or 8 
grammes), in the course of twenty-four hours. 

The effect of the chlorate of potassium is partly a gen- 
eral and partly a local one. 

The general effect may be obtained by the use of occa- 
sional larger doses ; but it is better not to strain the elim- 
inating powers of the system. The local effect, however, 
cannot be obtained with occasional doses, but only by 



TREATMENT. l6l 

doses so frequently repeated that the remedy is in almost 
constant contact with the diseased surface. Thus the 
doses, to produce the local effect, should be very small, 
but frequently administered. It is better that the daily 
quantity of twenty grains should be given in fifty or sixty 
doses than in eight or ten ; that is, the solution should be 
weak, and a drachm or half a drachm of such solution can 
be given every hour or every half-hour, or every fifteen 
or twenty minutes, care being taken that no water is given 
soon after the remedy has been administered, for obvious 
reasons. 

I have referred to these facts with so much emphasis, 
because of late an attempt has been made to introduce 
chlorate of potassium as the main remedy in bad cases of 
diphtheria, and, what is worse, in large doses. 

It is Seeligmuller especially who has recommended chlo- 
rate of potassium for that purpose in a saturated solution. 
Sachse also looks upon a saturated solution of chlorate of 
potassium as a panacea, inasmuch as he did " not lose a 
case out of one hundred/' except those, as he says, " which 
were hopeless at the beginning." A young colleague in 
our State also recommends chlorate of potassium (six 
drachms daily) as his sheet anchor in diphtheria (Louis 
Weigert, M.D., Hospit. Gaz., Jan. 16th, 1879). 

Seeligmuller administers a solution of one in twenty. 
Of this, he gives children of three years and over a table- 
spoonful every hour at first — doses which amount to half 
an ounce in twenty-four hours ; afterward every two or 
three hours. To children a little younger, he gives half a 
tablespoonful, and continues the treatment day and night. 
He insists upon the necessity of not adding any syrup to 
the solution, and also of not allowing the patient to drink 
within a short time after the administration of the rem- 
edy. In his opinion, the internal treatment suffices ; still 
he advises that the solution should be used as a wash, a 
gargle, and also should be snuffed. 

He says that the bad odor and fever, under that treat- 
11 



1 62 A TREATISE ON DIPHTHERIA. 

ment, disappear within a very short time. The number 
of cases which he first reported as treated successfully in 
this manner was fifteen. At the same time, he gave milk, 
broth, egg, and a small quantity of Tokay wine. These 
cases were published a number of years ago. Since that 
time he has modified his opinion to a certain extent. He 
says that chlorate of potassium may prove injurious, 
because of the possibility of the potassium acting upon the 
heart ; and that, when it does, the heart's action becomes 
either more or less frequent, and may be intermittent. 
On the other hand, he directs attention to the fact that 
diphtheria itself will act upon the heart in a similar way ; 
and, as soon as such symptoms occur, quinine, coffee, and 
wine are recommended. 

Digestion may also be interfered with by chlorate of 
potassium, inasmuch as when acute gastric catarrh is pres- 
ent the remedy is not well tolerated. In such cases, 
smaller quantities must be given, or the drug must be dis- 
continued altogether. In consequence of meeting with 
these drawbacks, he insists upon the above method of ad- 
ministering the remedy only during the first twenty-four or 
thirty-six hours. This modification he began particularly 
after a few of his patients died with a sensation of burning 
and soreness. 

I have reported his practice so extensively, because 1 
mean to raise my voice against it for the reason of its dan- 
gerousness. 

As early as i860, 1 advised strongly against the use of 
large doses of chlorate of potassium, but the translation 
of the paper I then published in the American Medical 
Times, which was printed in the Journal fiir Kinderkrank- 
heiten, in 1861, was so defective that I am not astonished 
at my warning having been overlooked on the European 
side of the Atlantic. The treatment is dangerous because 
of the largeness of the doses of the chlorate of potassium 
administered. 

Seeligmiiller himself reports a case of a boy six years 



TREATMENT. 1 63 

of age, who died within a very short time under the chlo- 
rate-of-potassium treatment, the main symptoms being 
copious greenish discharges, obstinate vomiting, and col- 
lapse. The kidneys were not examined after death, but 
the symptoms and the resemblance of these cases to a 
number of others of equal nature and result, prove them 
to be cases of nephritis depending upon over-doses of 
chlorate of potassium. 

Lacombe had under observation a man who took one 
ounce of potassium chlorate, intending to take an ounce of 
the sulphate of magnesium. The man died in convulsions, 
after having purged very freely, and the cause of death 
was regarded as excessive diarrhcea. The probability is, 
that it was a case of nephritis. 

Isambert, in his first reports upon the effects of chlorate 
of potassium, published more than twenty years ago, 
found among its effects increased diuresis, a sensation of 
heaviness and dragging in the lumbar region, such as is 
found after the administration of large doses of nitrate of 
potassium. 

Ferris reports a case of death from cyanosis, with absence 
of pulse, within a period of thirty-six hours after a table- 
spoonful of the chlorate of potassium was taken. 

He found the ventricles of the heart empty and con- 
tracted, while the auricles were distended with dark blood. 
The kidneys were not examined. 

When I myself, nearly twenty years ago, took single 
half-ounce and six-drachm doses of chlorate of potassium, 
I had a sensation of heaviness and dragging in the lumbar 
region, and increased renal secretion. I did not examine 
for albumen. 

The case of Dr. Fountain, of Davenport, Iowa, occur- 
ring at the very same time, is first mentioned by Alfred 
Stille (Therap. and Mat. Med., 2d ed., 1874, p. 922). He 
experimented upon himself, taking an ounce of the chlorate 
of potassium, and died in a week of nephritis (and enteritis).* 

* Alfred Stille publishes a letter of Dr. John M. Adler, of Davenport, Iowa. 



164 A TREATISE ON DIPHTHERIA. 

A case of death from chlorate of potassium, occurring in 
the practice of Dr. Krackowizer, I reported some years 
ago. It was that of a young lady who was told to use a 
solution of one ounce of chlorate of potassium as a mouth- 
wash and gargle. Instead of that, she swallowed the 
whole of the solution, and within three days died of neph- 
ritis. 

I have also, before this, referred to one of my own cases ; 
it was that of a man of thirty-odd years, who was told to 
use internally ten drachms of the chlorate of sodium, within 
six days. Instead of that, he took the entire quantity 

who was Dr. Fountain's friend and medical attendant. According to that letter 
(Stille's text makes it an ounce, and I know from my intercourse with Dr. 
Fountain that he took half an ounce previously), Fountain took half an ounce 
in a goblet of warm water at 8 A.M., on March 22d, 1861 ; free diuresis fol- 
lowed during the course of the day ; it ceased entirely at 4 p.m. He looked 
fatigued and was pale, but ate heartily at 7 p.m. ; was attacked with purg- 
ing, vomiting, and cramps after 8 p.m. ; was in dangerous collapse at 9.30, with 
vomiting and purging, with intense pain and cramps, skin cold, with the hue 
of a person nearly asphyxiated. He rallied, but retained an exceedingly dusky 
appearance of the skin. Between 6 and 8 A.M. the following day, he voided 
about two ounces of black-colored urine. After this, there was no secretion 
from the kidneys. " When he called my attention to the urine, he remarked 
that he feared the chlorate had seriously injured his kidneys." Immedi- 
ately after, the choleraic symptoms returned, with profound collapse, but he 
rallied again ; the purging ceased, and there was no further evacuation from 
the bowels during the six subsequent days of intense suffering. Vomiting and 
intense pain were incessant. He died just one week from the time of taking 
the chlorate. " The autopsy revealed a general intense inflammation of the 
entire alimentary tract, from the stomach to the rectum ; portions of the 
mucous membranes were destroyed, hanging in ragged shreds and patches, as 
if the intestine had been macerated a long time in a strong alkaline solution. 
The mucous membrane of the bladder gave a similar appearance. The bladder 
was empty. There were crystals of the chlorate in the pelvis of the kidneys, 
and a large bulk of extravasated urine (apparently) " (?) "under the capsule of 
one kidney." There is no mention made of the anatomical condition of the 
kidney, but there were two "ounces of bloody urine, and no more for six 
days," though the patient rallied after that second relapse also. There was 
general hypersemia and even ulcerations of the gastro-intestinal tract, whether 
primary or the result of the pertinacious vomiting and (in the beginning) purg- 
ing, is another question. It is seen in the violent gastro-intestinal symptoms 
of nephritis. 



TREATMENT. 1 65 

within six hours. Within twenty-four hours he suffered 
from diffuse nephritis. What little urine he passed was 
smoke-colored, and afterwards black. It contained a large 
percentage of albumen, blood, hyaline and granular casts. 
Then there was complete suppression. There was vomit- 
ing and diarrhoea, headaches and coma. He died on the 
fourth day, and the post-mortem examination exhibited 
acute diffuse nephritis. 

Dr. J. Lewis Smith, in a meeting in which the above 
statements of mine were referred to, reports a case of a 
child three or four years of age (see Medical Record, 
p. 397, 1878), who took three drachms of the chlorate of 
potassium in one day. After that only a few drops of 
bloody urine were discharged, and the child died at the 
end of twenty-four hours. 

In the same number of the same journal Dr. Hall reports 
a case of a child under one year of age, who took one 
drachm of the chlorate of potassium in a single night, with 
exactly the same symptoms and the same results. 

Conrad Kuster(D. Zeitsch. f. prakt. Med., 1877, No. 33), 
for no other purpose but to prove the essential identity of 
the punctated, maculated, membranaceous, croupous, and 
nephritic forms of diphtheria — similarly to most writers 
since Bard, Bretonneau, and myself amongst many — re- 
ports the following cases : 

A young woman of twenty, vigorous and blooming. 
Mild angina. Small, white specks on tonsils. Feels pretty 
well. A strong solution of chlorate of potassium for 
gargling and internal administration. No doses, however, 
reported. The doctor found her dying at daybreak the 
following morning. Relatives said that vomiting and 
diarrhoea commenced in the evening, but that they all 
slept and were awakened in the morning by the labored 
breathing of the patient. No post-mortem examination 
was made ; urine was not obtained. There was no dropsy, 
but the skin exhibited a peculiar dusky hue. 

A man of thirty, in vigorous health. Trifling macu- 



l66 A TREATISE ON DIPHTHERIA. 

lated diphtheritic angina. Strong- solution of chlorate of 
potassium as a gargle, and internally lime-water, besides. 
The tonsils cleared rapidly, but some malaise all the time. 
Urine albuminous. The doctor learned that the urine 
was peculiarly black on the third or fourth day. Gradual 
improvement, but urine albuminous a year and a half 
after. 

A boy of three years, in good health ; very mild, punc- 
tated, diphtheritic angina. Two other children had diph- 
theria seriously half a year previously, one of which died 
of laryngeal diphtheria. Gargle and administration of a 
strong solution of chlorate of potassium. Next day the 
doctor was notified the child was dying, and had passed 
black urine. So it was. The urine was black, a little 
greenish hue, moderately albuminous, the surface bluish 
white, the child dying. A good deal of vomiting. No 
dropsy. No post-mortem. 

A girl of four, also robust and vigorous. Mild angina, 
some trifling whitish marks, hardly visible in the tonsils. 
Gargles and administration of chlorate of potassium in 
strong solution. Appears nearly well both locally and gen- 
erally, within two days, but in the afternoon very sud- 
denly: vomiting, yawning, apathy, bluish-white complexion, 
accelerated and compressible pulse, skin cool. In the 
evening some urine, black with greenish hue, albuminous, 
contained hematine. On the following days, the color be- 
came more normal, and albumen less. On the fifth day, 
the danger was over, but the pulse remained frequent a 
long time. No dropsy. A slight return of albumen on 
the sixteenth day. 

Now Dr. Kiister claims all of these cases as acute neph- 
ritis, and adds verbatim : " There is here a peculiar resem- 
blance to renal irritation from carbolic acid poisoning. 
One is reminded of a medicinal poisoning, and would pre- 
sume its presence if carbolic acid had been used for external 
application. In my cases, the substance irritating the 
kidneys could be none but the chlorate of potassium. How- 



TREATMENT. 1 67 

ever, as this effect of chlorate of potassium has not been observed, 
as nephritis in diphtheria is, besides, nothing unusual, the 
latter must be claimed as the cause of the accidents." 

Kuster's facts are correct, his theory is not. His cases 
were mild, all of them tonsillar, no general symptoms, no 
adenitis ; in fact there is no, or very little danger, in 
consequence of the absence of lymph-vessel communi- 
cation between the tonsils and the rest of the body. 
Two of his four cases terminated fatally in a very short 
time ; two barely escaped. The same symptoms, the 
same nature of the disease in all. The cases seemed 
to the author like so many of poisoning by medication, 
and so they were. Unfortunately the author, otherwise 
known as careful, earnest, and conscientious, reports do 
doses, but in every case he speaks of strong solutions of 
chlorate of potassium, which appear to have been used 
rather indifferently or indiscriminately. Whoever has fol- 
lowed my remarks, and compares my own cases with his, 
will not hesitate to look upon his cases as such of acute 
nephritis brought on by excessive doses of chlorate of 
potassium. 

After all the previous remarks, the practical point I 
wish to make is this, that chlorate of potassium is by no 
means an indifferent remedy ; that it can prove, and has 
proved, dangerous and fatal in a number of instances, pro- 
ducing one of the most dangerous diseases — acute nephritis. 
We are not very careful in regard to the doses of alkalies 
in general, but in regard to the chlorate we ought to be 
very particular. The more so as the drug, from its well- 
known either authentic or alleged effects, has risen, or 
descended, into the ranks of popular medicines. Chlorate 
of potassium or sodium is used perhaps more than any other 
drug I am aware of. Its doses in domestic administration 
are not weighed but estimated ; it is not bought by the 
drachm or ounce, but the ten or twenty cents worth. It 
is given indiscriminately to young and old, for days or 
even weeks, for the public are more given to taking hold of a 



l68 A TREATISE ON DIPHTHERIA. 

remedy than to heed warnings. Besides, it has appeared to 
me that acute nephritis is a much more frequent occurrence 
now than it was twenty years ago. Chronic nephritis is 
certainly met with much oftener than formerly, and I know 
that many a death certificate ought to bear the inscription 
of nephritis instead of meningitis, convulsions, or acute 
pulmonary oedema. Why is that? Partly, assuredly, be- 
cause for twenty years past diphtheria has given rise to 
numerous cases of nephritis ; partly, however, I am afraid, 
because of the recklessness with which chlorate of potas- 
sium has become a popular remedy. 

In this respect the medical profession has done nothing 
to check its quackish use. For, with the exception of 
Alfred Stille, who knew Fountain's case and the destruct- 
ive powers of chlorate of potassium — it appears, however, 
that not the kidneys but the intestines were suspected — 
almost nobody has suspected it. Still, Isambert noticed, 
after large doses of the drug, increased elimination of urine, 
and after doses of twenty grammes a sensation of heaviness 
and pain in the renal region, without any other disorder. 

Buchheim (Arzneimittellehre, 1859), ^ is true, speaks of 
the irritation of the mucous membrane of the urinary 
tract, with frequent desire to micturate, and even of 
inflammation of the bladder and hematuria resulting 
from the use of the chlorate, as well as of the nitrate of 
potassium. Edlefsen, on the other hand, declares the 
remedy perfectly harmless (D. Arch. f. klin. Med., XIX., 

P- 97). 

In connection with a paper of mine on this subject (Med. 

Record, 1879, March 15th), which he quotes, F. Marchand 
(iiber d. gift. Wirkung des Kali chloricum in grosseren 
Dosen, Sitzgsber. d. Naturforschenden Ges. zu Halle, Feb. 
8th, '79, and Virch. Arch., vol. yj) has also observed in- 
toxication by potassium chlorate. Death ensued either 
suddenly, or after some days. In the former cases, the blood 
was brown, but no changes took place in the organs ; in 
the latter, an affection of the kidneys resulted in the emission 



TREATMENT. 1 69 

of a urine loaded with decomposed blood-cells and de- 
pended on obstruction of renal capillaries by the changed 
blood-corpuscles. Experiments made on dogs, which con- 
sisted in potassium chlorate being either administered in- 
ternally or thrown into the abdominal cavity, had the same 
effect. Blood taken from time to time proved an increasing 
discoloration of the same ; it resembled the changes tak- 
ing place in blood after severe burns of the surface. When 
death did not occur suddenly, the urine changed after 
twelve or twenty -four hours. Spectroscopic examination 
of such blood yielded the character of methasmoglobin 
(the same changes which take place when blood is mixed 
with potassium chlorate). 

Finally, E. Baginski,* referring to my own and Mar- 
chand's communications, reports four clinical observations 
of a nature similar to that of my own cases. I have no 
doubt but that the number of unfortunate cases of the 
kind will increase unless my warning be heeded. 

My views concerning the treatment of diphtheria are 
based on the principles laid down in the discussion of the 
pathology of this disease. Although diphtheria is, after 
all, a constitutional disorder, yet it frequently has a local in- 
ception ; in other words, the infection enters into the gen- 
eral system at a certain circumscribed locality. In many 
cases, this locality is the same, namely, the fauces. From 
this stand-point, constitutional diphtheria may be com- 
pared to the septic absorption occurring in wounds and in 
the puerperal condition, and for that reason we shall be 
obliged to rely principally on the method of treatment 
that is most serviceable in diseases of wounds, and puer- 
peral fever after delivery, to wit : local disinfection. 

While, however, we may congratulate ourselves on a posi- 
tive knowledge of the effects of disinfecting agents upon 
accessible putrid fluids, we have no proofs of our ability to 



* Ueber toxische Wirkungen des Kali chloricum, Arch. f. Kinderheilkunde, 
1880, p. 100. 



170 A TREATISE ON DIPHTHERIA. 

disinfect the blood in the living body. True, we may 
claim that we possess remedies which enable the body to 
resist the action of the poison, but we cannot yet assert 
that we have at our command remedies which, when 
absorbed into the blood, are able to destroy the poisonous 
elements contained therein. It is possible that salicylic 
acid forms an exception ; yet concentrated salicylic acid, 
when mixed with diphtheritic scrapings from the tongue, 
did not destroy the infectious qualities thereof. Besides, 
it ought not to be overlooked that salicylic acid, when 
introduced into the system by internal administration, 
forms at once salicylates ; mainly sodium salicylate, which 
is not a disinfectant. 

Moreover, if the pathological process in question, and 
pathological processes in general, were the result of bac- 
teria, and bacteria only (or, according to the botanist 
Naegeli, organized substance of some kind), the therapeu- 
tics would necessarily consist in destroying these bac- 
teria, these organized substances. But, when we read of 
the assurance with which antiseptic medicines are recom- 
mended for internal administration, we are certainly 
entitled to our share of astonishment. It is a well-known 
fact that the most thorough mixture of antiseptic with 
putrid material is required to destroy bacteria, but with 
the most child-like faith do we send our liquids down into 
other people's stomachs, expecting every antiseptic drop 
to look out for its duty. It is expected to be absorbed, 
and being swept into the circulation, to find its way to the 
" nests " of micrococci stowed away in gangrenous tissue 
out of reach of vascular or lymphatic circulation, to fall 
upon the enemies of tissue and mankind and commence 
their deadly combat. It is also expected that a fraction 
of a grain of sodium benzoate atomized down into a pul- 
monary abscess swarming with bacteria should have the 
same effect; while in the bottle and in the test-tube, we know 
that a thorough shaking with a well-known and large pro- 



TREATMENT. 171 

portion of antiseptic admixture is required for a satisfac- 
tory effect. 

N. C. Scharrenbroich's and Appert's (Virch. Arch., 61, 
p. 364) observations on the effect of quinine are, for the 
time being, of not much importance for practical medi- 
cine. It is true that leukocytes become dark and seem- 
ingly granulated in a solution of neutral muriate of qui- 
nine. 1 : 200-1 : 2000, and that amoeboid movements are 
imperceptible afterwards. It is also true that doses of 
3T0T or 4 0*0 °^ tne we ight. of the body of a frog render 
both emigration and marginal position of leukocytes 
impossible, and that the above-mentioned changes will 
take place; and further, that pulse and circulation are 
very much retarded. But such doses cannot be employed 
in practising on the human being, and the full effect of 
the drug cannot, therefore, be obtained, provided that the 
doses required in men are in any way proportionate to 
those in the frog. Even though they be much smaller, 
like those calculated by Binz, they would be too large to 
be administered. 

Prevention, after all, is but in part the business of the 
physician. It is mostly that of the individual, or the com- 
plex of individuals, viz., town, state, nation. Those sick 
with diphtheria must be isolated, though the case appear 
ever so mild, and if possible, the other children sent out 
of the house altogether. If that be impossible, let 
them remain outside the house, in open air, as long as 
feasible, with open bed-room windows during the night, 
in the most distant part of the house, and let their throats 
be examined every day. The watching eye of a father or 
mother will discover deviations from the norm, so that the 
physician can be notified. Let the temperatures of the 
well children be taken once a day, in the rectum. Ten 
minutes of a mother's time are well paid by the discovery 
of a slight anomaly, which may require the presence of the 
physician. Happily, there are many mothers who keep 
and value a self-registering thermometer as an important 



172 A TREATISE ON DIPHTHERIA. 

addition to their household articles. The attendant upon 
a case of diphtheria must not get in contact with the 
rest of the family, particularly the children, for the poison 
may be carried, though the carrier remain well, or appar- 
ently well. Unnecessary petting of the patient on the 
part of the well ought to be avoided, kissing forbidden, 
the bed-clothing and linen to be changed often, and disin- 
fected, the air cool and often changed. 

The well, or apparently well children of a family that 
has diphtheria at home, must not go to school nor to 
church. The former necessity is beginning to be recog- 
nized by the authorities and teachers, and also in conse- 
quence of partially enforced habit by parents, the latter 
will be resisted longer. Schools ought to be closed en- 
tirely when a number of cases have occurred. Even when 
the school children have not been affected to a great 
extent, but a diphtheria epidemic has commenced in 
earnest, it will be better to close the schools for a time. 
If that be not advisable, the teacher ought to be taught to 
examine throats, and directed to examine every child's 
throat in the morning, and return home every one barely 
suspicious. 

In times of an epidemic, every public place, theatre, 
ball-room, dining-hall, tavern, ought to be treated like a 
hospital. Where there is a large conflux of people, 
there are certainly many who carry the disease with 
them. Disinfection must be enforced by the authorities 
in regular intervals. Public vehicles must be treated in 
the same manner. That it should be so when a case of 
small-pox has happened to be carried in such, appears 
quite natural. Hardly a livery stable keeper would be 
found who would not be anxious to destroy the possibility 
of infection in any of his coaches. He must learn that 
diphtheria is, or may be, as dangerous a passenger as vari- 
ola. And what is valid in the case of a poor hack, is more 
so in that of railroad cars, whether emigrant or Pullman. 
They ought to be thoroughly disinfected in times of an 



TREATMENT. 1 73 

epidemic, in regular intervals, for the high roads of travel 
have always been those of epidemic diseases, and railroad 
officers and their families have often been the first victims 
of the imported scourge. Can that be accomplished ? 
Will not railroad companies resist a plan of regular dis- 
infections because of its expensiveness ? Will there not 
be an outcry against this despotic violation of the rights 
of the citizen, the independence of the money bag? Cer- 
tainly there will be. But there was also, when muni- 
cipal authorities commenced to compel parents to keep 
their children at home when they had contagious diseases 
in the family, and when a small-pox patient was arrested be- 
cause of endangering the passengers in a public vehicle. 
In such cases, it is not society that tyrannizes the individ- 
ual; it is the individual that endangers society. And 
society begins at last, even in America, to believe in the 
rights of the commonwealth, and not in the rights of the 
democratic person only. The establishment of State and 
National Boards of Health proves that the narrow- 
hearted theories of the strict constructionists have not 
only disappeared from our politics, but also from the con- 
science and intellect of society. 

The sick-room must be kept cool, the windows kept open 
— more or less — in the night, the floor frequently washed, 
the linen soaked at once, the excrements removed. Dead 
bodies ought to be kept moist, for infectious material, 
chemical or otherwise, will spread more easily when dry. 
Attendants must not talk unnecessarily over the mouth 
or diphtheritic wounds of the patient, and will do well to 
carry a little dry loose cotton — to be changed often — in 
each of the nostrils, for it prevents the transport of infec- 
tion from septic material to such as would be considered 
exposed under ordinary circumstances (Wernich in F. 
Cohn's Beitr., III., 1859, P- ll S)- 

A very urgent and important mode of prevention consists 
in disinfection. Its requirements may be stated as of a double 
nature. Those who still believe in bacteria as the causes and 



174 A TREATISE ON DIPHTHERIA. 

main representatives of infectious diseases do not consider 
disinfection complete unless the disinfectants used have 
succeeded in destroying the vitality of bacteria. Now, 
about the same time experiments have been made in both 
hemispheres, the results of which are singularly unanim- 
ous. Thus Schotte and Gartner, under the orders of the 
Surgeon-General of the German Navy, publish a report 
with experiments on the question, how much carbolic acid 
or how much sulphurous acid is required for the destruc- 
tion of bacteria (" Zur Todtung des kleinsten Lebens "),* 
with the following result, viz., that a sure disinfection can- 
not be accomplished on board ships by the evaporation of 
carbolic acid or by burning sulphur, because of the large 
quantities required for that end, but that there is a fair hope 
to find a substance which, when in solution, is capable of 
surely destroying bacteria in watery solutions or in 
garments. And George M. Sternberg, U. S. A., in his ex- 
periments with disinfectants, made at the request of the 
National Board of Health (Bull. No. 47, May 22d, 1880), 
comes to the following conclusions, viz., that the amount 
of pure carbolic acid required to destroy the vitality of 
bacteria is equal to about seventeen pounds in a room 
twelve feet square and twelve feet high (capacity 1728 
cubic feet) and to fulfil the conditions oi the experiments 
on a large scale it would be necessary to scatter this 
amount over the floor of a room having these dimensions, 
and to suspend articles to be disinfected near the floor for 
at least six hours, care being taken that all apertures are 
closed, so that the fumes of the acid may not escape. 
Another experiment (No. 43 in the series) shows that four 
times this amount (sixty-eight pounds) of " crude " acid 
placed upon the floor of a room of the same size would 
not destroy the vitality of bacteria exposed in the room 
for six hours. These experiments show that the popular 
idea, shared, perhaps, by some physicians, that an odor 

* D. Viertelj. f. offentl. Gesundheitspflege, 1880, XII., p. 337. 



TREATMENT. 175 

of carbolic acid in the sick-room, or in a foul privy, is 
evidence that the place is disinfected, is entirely fallacious, 
and, in fact, that the use of this agent as a powerful disin- 
fectant is impracticable, because of the expense of the 
pure acid and the enormous quantity required to produce 
the desired result. 

The warning is appropriate, and when it will be heeded, 
much carelessness will be avoided, and much danger 
averted. But, perhaps, the case is not so bad, after all, 
as we might conclude from the results of the observations 
of the medical men engaged in the above experiments. 
The uniformity of their results proves almost to a cer- 
tainty that they are quite correct in regard to bacteria, 
but those who do not see in bacteria the cause and essence 
of all infectious diseases, especially diphtheria, will look 
to disinfection as their safeguard, without fearing to be 
baffled in their practical efforts to avert disease. Two 
hundred years ago, when the first infusoria were dis- 
covered, they were also accused of being the cause of in- 
fectious diseases. They were met with the thunder of 
cannons ; but when that refused to be effective, it was at- 
tempted to bewitch the infusoria with music. A pound 
of pure carbolic acid to a hundred cubic feet looks very 
much like the cannon ball, but has the advantage, accord- 
ing to Sternberg, of being effective ; may be that what 
the National Board of Health has recommended to us, in 
the shape of their Circular No. 1,* is also more effective 
than the music of old. I cannot do better than to copy it 
from Bulletin No. 10, September 6th, 1879. 

Instructions for disinfection. 

Disinfection is the destruction of the poisons of infec- 
tious and contagious diseases. 

Deodorizers, or substances which destory smells, are 



* Signed by George F. Baker, Phila. ; C. F. Chandler, New York ; Henry 
Draper, New York ; Edward G. Janeway, New York ; Ira Remsen, Balti- 
more ; S. O. Vander Poel Albany. 



176 A TREATISE ON DIPHTHERIA. 

not necessarily disinfectants, and disinfectants do not 
necessarily have an odor. 

Disinfection cannot compensate for want of cleanliness 
nor of ventilation. 

I. Disinfectants to be employed. 

1. Roll-sulphur (brimstone) for fumigation. 

2. Sulphate of iron (copperas) dissolved in water in the 
proportion of one and a half pounds to the gallon ; for 
soil, sewers, etc. 

3. Sulphate of zinc and common salt, dissolved together 
in water in the proportion of four ounces sulphate and two 
ounces salt to the gallon ; for clothing, bed-linen, etc. 

Note. — Carbolic acid is not included in the above list for the following 
reasons : It is very difficult to determine the quality of the commercial ar- 
ticle, and the purchaser can never be certain of securing it of proper strength ; 
it is expensive when of good quality, and experience has shown that it must be 
employed in comparatively large quantities to be of any use ; it is liable by 
its strong odor to give a false sense of security. 

II. How to use disinfectants. 

1. In the sick-room. — The most available agents are 
fresh air and cleanliness. The clothing, towels, bed-linen, 
etc., should, on removal from the patient, and before they 
are taken from the room, be placed in a pail or tub of the 
zinc solution, boiling-hot if possible. 

All discharges should either be received in vessels con- 
taining copperas solution, or. when this is impracticable, 
should be immediately covered with copperas solution. 
All vessels used about the patient should be cleansed with 
the same solution. 

Unnecessary furniture — especially that which is stuffed 
— carpets and hangings, should, when possible, be re- 
moved from the room at the outset ; otherwise, they 
should remain for subsequent fumigation and treatment. 

2. Fumigation with sulphur is the only practical method 
for disinfecting the house. For this purpose the rooms 
to be disinfected must be vacated. Heavy clothing, 
blankets, bedding, and other articles which cannot be 
treated with zinc solution, should be opened and exposed 



TREATMENT. 1 77 

during fumigation, as directed below. Close the rooms 
as tightly as possible, place the sulphur in iron pans sup- 
ported upon bricks placed in wash-tubs containing a little 
water, set it on fire by hot coals or with the aid of a spoon- 
ful of alcohol, and allow the room to remain closed for 
twenty-four hours. For a room about ten feet square, at 
least two pounds of sulphur should be used ; for larger 
rooms, proportionately increased quantities. 

3. Premises. — Cellars, yards, stables, gutters, privies, 
cesspools, water-closets, drains, sewers, etc., should be 
frequently and liberally treated with copperas solution. 
The copperas solution is easily prepared by hanging a 
basket containing about sixty pounds of copperas in a 
barrel of water. 

4. Body and bed-clothing, etc. — It is best to burn all 
articles which have been in contact with persons sick with 
contagious or infectious diseases. Articles too valuable 
to be destroyed should be treated as follows : 

A. Cotton, linen, flannel, blankets, etc., should be treated 
with the boiling hot zinc solution ; introduce piece by 
piece ; secure thorough wetting, and boil for at least half 
an hour. 

B. Heavy woollen clothing, silks, furs, stuffed bed- 
covers, beds, and other articles which cannot be treated 
with the zinc solution, should be hung in the room during 
fumigation, their surfaces thoroughly exposed, and pockets 
turned inside out. Afterwards, they should be hung in 
the open air, beaten, and shaken. Pillows, beds, stuffed 
mattresses, upholstered furniture, etc., should be cut open, 
the contents spread out and thoroughly fumigated. Car- 
pets are best fumigated on the floor, but should after- 
wards be removed to the open air and thoroughly beaten. 

5. Corpses should be thoroughly washed with a zinc 

solution of double strength ; should then be wrapped in 

a sheet wet with the zinc solution, and buried at once. 

Metallic, metal-lined, or air-tight coffins should be used 
12 



I78 A TREATISE ON DIPHTHERIA. 

when possible, certainly when the body is to be trans- 
ported for any considerable distance. 

SPECIAL TREATMENT. 

The local remedies may be conveniently divided into 
three classes. The first includes those which dissolve the 
pseudo-membrane, and thereby afford an opportunity to 
remove it ; the second, those which appropriately mod- 
ify the surface from which the membrane has been re- 
moved, or the membrane itself ; the third, the real anti- 
septic agents which are credited with being- able both to 
bring- about chemical changes and to destroy parasitic 
organisms, and which are, therefore, believed to be ap- 
propriate by those who consider diphtheria either due to a 
chemical poison or to the presence and rapid proliferation 
of bacteria. 

It is mostly when the pseudo-membrane has its seat in 
the larynx that it is highly important to dissolve it as 
rapidly as possible. Of the vast number of remedies that 
have been recommended for this purpose, but four have 
held their ground up to the present day, to wit : Lime- 
water, glycerine, lactic acid, and steam. 

INHALATIONS OF STEAM. 

Quite remarkable effects have been expected of, and 
claimed for, them. It is true that pseudo-membranes, like 
everything else, become softened by the warm vapors. It is 
also probable that steam increases the secretion of the 
mucous glands, and thereby possibly loosens the overlying 
membranes and favors their removal, but it must not be 
forgotten that it also softens the healthy tissues, and that 
this change in character enables the poison, whatever be 
its nature, to penetrate more deeply into them. These 
two hypotheses must be kept in mind when, in any case, 
the question of the employment of steam arises. 

Steam for the purpose of softening the tissues and of 
provoking the secretion of mucus and suppuration has 



TREATMENT. 1 79 

been used to a considerable extent ; in fact, in England 
and America it constitutes an important part of the 
treatment of diphtheria of the larynx. The patient 
must inhale it directly from a vessel, or in a tent 
which is more or less closed, or breathe the atmosphere 
of the room after it has been saturated therewith. For 
the latter purpose, water is kept constantly boiling, or 
lime slaked, or red-hot stones put in water from time to 
time. The results from this procedure in diphtheria of 
the larynx have not always been pleasant. I have repeat- 
edly had the joy of seeing children, with croup, become less 
cyanotic after their removal from an atmosphere of vapor, 
and I can readily see that pure atmospheric air would be 
more agreeable and wholesome to a child with stenosis of 
the larynx than an atmosphere laden with steam. Of 
course, this remark does not apply to cases of pseudo- 
croup and bronchitis, which are generally benefited by a 
warm, moist atmosphere. In pharyngeal diphtheria I 
anticipate but little from the softening and suppuration- 
producing properties of steam. Whoever has noticed the 
obstinacy with which diphtheritic membranes and infiltra- 
tions resist all treatment, for days, and even beyond a 
week, will hardly attribute the recovery from a mild and 
favorable case of diphtheria of the tonsils, and of light 
pharyngeal diphtheria, to moist air. Those, however, 
who deem it judicious to employ steam as a vehicle for 
carbolic acid, salicylic acid, chloride of sodium, chlorate 
of potassium, or lime, had best resort to the atomizer for 
applying these remedies. It can be used without trouble ; 
most children are sufficiently intelligent to allow a spray 
of nebulized solution to be directed upon the fauces and 
larynx every ten or fifteen minutes, in case of necessity. 

On the other hand — and again I emphasize the fact, that 
I know of no specifics for diphtheria, and recommend no 
uniform treatment for all persons, and all cases — I have 
seen cases of fibrinous bronchitis getting well, when I had 
every reason to attribute the recovery to the persistent 



l8o A TREATISE ON DIPHTHERIA. 

use of steam. As in the case of croup I have detailed in 
another place, the child was kept in steam and turpentine 
vapor more than four days, so I have seen Dr. F. Zinsser 
lock up a baby in a small bath-room, with one window, 
and let the hot water run persistently, for days, fill the 
room so as to produce a constant fog, and make every per- 
son in the room dripping. The result was highly gratify- 
ing ; the baby got well ; and so did another, whom I had 
the good fortune to benefit by my experience in that case. 
Again, I insist, steam will improve, steam will impair. 
Ars longa. Individualizing is a great art. In regard to 
the steam therapeutics it is, however, not so difficult. Its 
object is to soften, but principally to increase the secre- 
tion from the mucous membrane, and thereby throw off 
the superjacent membrane. This can be done to advan- 
tage only where there is a natural tendency to it, that is, 
where there are a great many muciparous follicles under 
a cylindrical or fimbriated epithelium. This is the con- 
dition on part of the pharynx, but not on the tonsils, in a 
small portion of the larynx, in the trachea and bronchi, not 
on the vocal cords. Wherever there is pavement epi- 
thelium on the normal surface, and where the membrane 
is imbedded into the tissue, steam can hardly be expected 
to do good. In the other cases it will. Thus the locality 
of the diphtheritic process determines to a great extent 
whether steam is indicated or not. If it be used, the 
necessity of a full supply of atmospheric air must not be 
disregarded. Steam, with an over-heated room and with- 
out pure air, is liable to be as injurious as steam in pure 
air is beneficial in a number of cases. 

There can be no better proof for the necessity of indi- 
vidualizing, and the impossibility of treating all cases alike, 
than the fact that many will do well under steam treat- 
ment, and others are certainly injured by it. We ought 
not to be surprised at the repetition of the same old expe- 
rience that, when two do the same thing, it may not be 
the same thing. Two means as well patients as doctors. 



TREATMENT. l8l 

The object for which steam is inhaled is to soften and 
remove membranes. When that can be accomplished 
without reducing the required amount of oxygen, all is 
well ; when, however, respiration is annoyed or interfered 
with, the contra-indication to steam is as clear as its indi- 
cation is in more favorable cases. Nor is this different in 
cases of obstinate pneumonia, where steam may be either 
beneficial or injurious, according to circumstances. 

WATER 

may be made serviceable in quite a different manner. Its 
effect, when taken in large quantities, under normal or 
abnormal circumstances, on the skin is a matter of daily 
experience. Copious perspiration is its immediate result. 
The very same effect is produced on all integuments and 
amongst the mucous membranes, principally on those of 
the respiratory and digestive organs. It is particularly 
plain when water is drunk during a nasal catarrh, when 
the discharge increases immediately ; while, on the other 
hand, abstinence from drinking reduces the secretion. 
Much drinking moistens the mucous membranes, rhonchi 
become looser and moister, and the aim of raising and 
macerating membranes, if not reached, is certainly ren- 
dered more accessible. While one is done, however, the 
other need not be omitted, and a judicious combination 
of the methods of supplying the muciparous glands with 
plenty of fluid suggests itself readily to the thoughtful 
practitioner in the appropriate cases. Besides profes- 
sional hydropathists, I know of but one (C. Rauchfuss, in 
C. Gerhardt's Handb. d. Kinderkr., III., 2, 1878) who fav- 
ors the plentiful use of water, either by itself, from 100- 
200 grammes (3 to 6 ounces) every hour, or oftener, or 
mixed in alcoholic beverages, warm punch, etc. 

COLD WATER, AND COLD IN GENERAL, 

are useful in different ways. Severe inflammatory symp- 
toms, in diphtheria and other affections, such as redness 



1 82 A TREATISE ON DIPHTHERIA. 

of the throat, great pain, swelling of the glands, require 
cold applications, either an ice-bag or ice-cold cloths, 
well pressed out and frequently changed. They must, 
however, be placed where they can do most good ; in 
laryngeal diphtheria around the neck, in pharyngeal diph- 
theria and glandular swelling over the affected part. 
Therefore, the flannel cloth which covers the whole of the 
application must be tied over the head, and not behind. 
When ice-bags are used, care is to be taken lest they 
should be too large ; if so, they will not affect the desired 
spot at all. Small pieces of ice frequently swallowed are 
greatly relished by the patient; water-ices in small quan- 
tities will render the same service ; ice-cream, in half-tea- 
spoon or teaspoon doses every five or ten minutes, adds to 
the necessary nutriment. When the fever is high, and the 
surface hot, sponging with tepid or cold water, or water 
and alcohol, will mitigate both. For the cold bath or the cold 
partial pack (trunk and upper part of thighs), the general 
indications hold good. As a rule, 1 favor the latter. For 
many cases have such a tendency to debility and collapse 
that sometimes the circulation of the surface of the body 
is badly interfered with by cold bathing. Therefore, a 
contra-indication to cold bathing must be found at once 
in cold feet, either before or after a bath. When, unfor- 
tunately, the feet do not recover their normal temperature 
in a very short time, they ought to be warmed artificially, 
and the cold bath not repeated. In such cases, the cold 
pack, however, is still indicated. A linen or cotton cloth, 
large enough to cover the trunk and half of the thighs, is 
dipped in cold water, well pressed out, and the body 
of the patient wrapped tightly in it. The arms remain 
outside, the whole body is then wrapped up in a blan- 
ket, the feet may be warmed meanwhile when neces- 
sary, and the cold pack repeated as often as required to 
reduce the temperature, viz., once every five minutes, 
every half-hour, every hour. 

The contra-indications to the use of cold have in part 



TREATMENT. 1 83 

been alluded to. Very young infants bear it but to a limited 
extent. The beginning of recovery contra-indicates it, 
unless for some local cause, for instance, an inflamed 
gland. Extensive use of cold water or ice is also forbid- 
den when there is no fever, where there is perhaps an 
abnormally low temperature, where we have to deal with 
the septic or gangrenous form of diphtheria, where the 
vitality is low, and the mucous membranes pale or even 
cyanotic. In such cases, on the contrary, while unlimited 
internal stimulation is required, the hot bath, or hot pack, 
and hot injections into the bowels will be found beneficial. 

LIME-WATER, GLYCERINE, AND LACTIC ACID 

decidedly dissolve the membranes, but whether there is 
sufficient time in most cases to produce a curative effect 
is another matter. Concerning lime-water and glycerine, 
I have employed a combination of equal parts of both. 
In cases of diphtheria in children of three or four years 
and over, I think that my favorable results were owing 
to assiduous cleansing of the throat and nose. In vastly 
more than one hundred cases after the completion of 
tracheotomy, I have employed the same combination, re- 
duced to a spray by means of the atomizer, and directed 
into the opening in the trachea, but must confess that my 
results left much to be wished for. Particularly in the 
last few years, in which the prevailing epidemic of diph- 
theria hardly ever intermitted, my results from tracheot- 
omy have been very unsatisfactory, because, amongst 
other measures undertaken for the same purpose, the spray 
of lime-water and glycerine was not of the least service 
in preventing the descent of the process into the bronchi. 
Long ago I have begun to rely less implicitly upon lime- 
water, where a local action upon the larynx and trachea is 
called for, owing to its instantaneous conversion into car- 
bonate of lime.* 

* Dr. Billington takes exception to my remarks on the inefficiency of lime- 
water made before the New York Academy of Medicine, on the occasion of 



1 84 A TREATISE ON DIPHTHERIA. 

lactic ACID, too, dissolved in from ten to twenty-five 
parts of water, has yielded no better results in my hands. 
I can cite but one case, that of a boy of five years, who, 
under the constant spray of lactic acid into the throat, and 
as far as possible into the air-passages, recovered from an 
attack of croup after a number of days, although trache- 
otomy had not been performed. A similar success has 
been communicated to me by Dr. Wm. Chamberlain. 
Those cases of tracheotomy which I subsequently treated 
with a spray of lactic acid did not terminate more 
favorably than those in which lime-water and glycerine 
were employed. I have not been able to convince myself 
of the locally solvent action of PEPSIN. With NEURIN I 
have no experience. It was both externally and internally 
first used by Winiwarter, and is recommended because 
of its being an alkaline antifermentative, while all other 

the doctor's reading a detailed account of forty cases of diphtheria. In an 
open letter to the Editor of the Medical Record, over his name and ad- 
dress, he says it occurred to him that the question might be answered by a 
very simple experiment. He says : " I was permitted, by a patient who has 
an unusually patent and tolerant threat, to hold a bit of red litmus paper at 
the end of a wire, and protected from the action of the saliva by coils of wire, 
well back in the pharynx, the patient being instructed to breathe naturally. 
I then, with the atomizer -which I use in treating diphtheria, and in exactly 
the same manner, threw the spray of lime-water into the throat. In fifteen 
seconds the red litmus paper was turned blue — this change occurring quite as 
rapidly and as completely as when the same experiment is performed in the 
outer atmosphere. In other words, it was not appreciably modified by the 
breath. Again, litmus paper moistened with lime-water can be held in the 
breath for some minutes before its blueness is perceptibly affected by it. This 
experiment seems to me to show that lime-water spray reaches the fauces and 
pharynx as lime-water, and does not immediately thereafter cease to be lime- 
water. When spray thrown into the throat by this method enters the larynx, 
it does so by being drawn in thither by the inspired breath which is compara- 
tively free from carbonic acid, and it therefore reaches the walls of the larynx 
as lime-water, and then continues to be lime-water for a certain length of 
time." 

So the red litmus paper, while dry, was not easily affected by the carbonic 
acid of the breath? Why should it, when no chemical text-book makes a 
statement to the contrary? And the red litmus paper was turned blue by cov- 
ering it with lime-water — indeed! Litmus paper owes its very existence 



TREATMENT. 1 85 

antiseptics are acid, and, therefore, must undergo changes 
before they can be admitted to the circulation. It is 
claimed that the foetid odor disappears readily, and that 
membranes are dissolved more easily by its three-per-cent 
solution than other dissolvents. 

C. Edel recommended (Med. Rec, Jan. 19th, 1878) the 
treatment of diphtheria by 

TURPENTINE INHALATIONS. 

Fifteen drops of oil of turpentine are inhaled from a com- 
mon inhalation apparatus, which is placed at a distance of 
three inches from the mouth of the patient, for a period of 
ten minutes every hour. He claims recoveries in from 
twelve to forty-eight hours. Taube (Deutsche Z. f. prakt. 
Med., 1878, No. 36) also uses oil of turpentine, but, as far 



and reputation to the fact that it is so very sensitive, and shows the effect of 
either acid or alkali so readily, and in the most minute quantities. Let us 
remember that the atomizing apparatus with each pressure sprays about 
i-500th of a grain of lime ; that, therefore, it takes hours to send a grain of 
lime into the throat ; that, however, a membrane has to lie immersed in 
lime-water for hours before it shows signs of maceration ; that lime-water 
introduced into the trachea even, through the tracheotomy tube, does not 
dissolve membranes to any satisfactory degree — though they be only deposited 
upon, and not (as on the tonsils and parts of the larynx) into the tissue ; and 
though in the trachea the mucus of thousands of glands readily aids in mac- 
erating ; and though in the opened trachea the lime-water certainly reaches 
the membrane, which is not so certain in regard to pharyngeal or even laryn- 
geal membranes when you atomize into the mouth and pharynx. And as the 
doctor relies on experiments, he can add one which he made when he. was quite 
young. Let him blow into as much as half a pint of lime-water (containing 
about four grains of lime), and the whole of that lime will be a turbid cloud of 
carbonate after a very few expirations. 

Here is another experiment : Let the doctor dip blue litmus paper into 
moistened carbonate of lime, or a solution of sodium carbonate, or even bicar- 
bonate, and his blue litmus paper will behave exactly as it does in his patient's 
throat, to wit, it will remain blue ; which is not remarkable at all ; and then 
let him breathe upon the litmus paper moistened with calcium carbonate ever 
so long, and it will remain blue. Should it not? In his experiments on his 
patient's throat nothing is proved except that the newly formed calcium car- 
bonate secures the blue color to his litmus paper for some time. That is all, 
and requires no proof. 



1 86 A TREATISE ON DIPHTHERIA. 

as the effect of the latter is concerned, it cannot be appre- 
ciated, as his treatment is not a uniform one. For he 
adds two or three daily injections into the tonsils of a 
three-per-cent solution of carbolic acid, one or two tea- 
spoons of claret every hour, ice externally, two or three 
warm baths daily, with cold shower, milk, egg, infus. digi- 
tal. 0.5:80.0, with ac. benzoic 1.0, etc. His dose of 
oil of turpentine is like that of Edel ; in order to avoid 
local irritation, he oils the face and covers the eyes with a 
bandage ; he reports that he never saw renal or cerebral 
disorders following its administration. 

For years I was in the habit of using turpentine, either 
the oil or the rectified spirits, as an inhalation in bad cases 
of pneumonia, where hepatization was very extensive,, 
and expectoration and resolution did not commence, with 
very good result in children and adults. The vapors of 
turpentine are so volatile and penetrating (and certainlv 
the procedure of Taube so disagreeable to the patient, if 
it be permitted at all by children) that the usual method 
of inhaling from an apparatus appeared to me to be very 
superfluous. I allow the patient to remain in his bed, and 
keep water boiling constantly on an alcohol lamp, on the 
stove, or over the gas. A tablespoonful of spir. rect. or ol. 
terebinth., more or less, is poured on the water, care being 
taken that nothing is spilled in the fire. Thus the room 
is constantly filled with a penetrating odor of turpentine, 
which is not at all disagreeable, even when in great con- 
centration. The effects are very satisfactory indeed. 
Where circumstances allowed or required it, I raised a tent 
over the bed, large enough not to give inconvenience to 
the patient, and to admit either the whole apparatus or 
the tube containing the mixed vapor of water and turpen- 
tine. This plan I followed also in the case of laryngeal 
diphtheria of a girl of two years, in the children's service 
of the Mount Sinai Hospital. The baby was in a room 
of her own, with a nurse. A tent was raised over the bed. 
Four days and nights was she exposed to the water and 



TREATMENT. 1 87 

turpentine treatment, awake or asleep ; not only she, but 
also the nurse, whose presence under the tent was insisted 
upon by the patient whenever she was awake. It ought 
to be stated that the case was not (or was not allowed to 
become ?) a very serious one. It was serious enough to be 
diagnosticable, to produce hoarseness, aphonia, dyspnoea, 
and to render the perception of pulmonary murmurs impos- 
sible ; but there never was cyanosis with the exception of a 
slight hue on the upper lip. She got well, with no other 
treatment but my iron and pot. chlor. solution. As a 
practical addition, I may say that the nurse did not suffer 
much more than she would have done after the same time 
passed in a close room, and in constant attendance upon 
an exacting and whimsical patient. 

AMMONIUM CHLORIDE, 

muriate of ammonia, may sometimes be used to advantage 
for its softening and liquefying effects. Its internal admin- 
istration in bronchial and tracheo-laryngeal catarrh is so 
old that it has several times been obsolete. Of late, more 
stimulant effects have been attributed to it than it actu- 
ally possesses. But its liquefying action, in cases where 
the secretion of mucus is defective, and expectoration 
slow and viscid, is undoubted. Thus it proves valuable 
in many cases of simple catarrh, both when administered 
internally and inhaled. The latter mode of inhalation I 
have often resorted to, and believe that its macerating 
influence has been of service to me in cases of laryngeal 
diphtheria. Half a teaspoonful of the pure salt is spread 
on the stove, or burned over alcohol or gas. It evaporates 
immediately and fills the room, or the tent, with a white 
cloud, which, when dense, excites coughing. But it does 
not irritate to any uncomfortable degree, and the process 
may be repeated in an interval of an hour or more. 

HYDRARGYRUM 

has been used in all and any children's diseases. When I 



1 88 A TREATISE ON DIPHTHERIA. 

was young, I seldom saw a prescription for a child without 
some little or much mercury on it. That, therefore, it 
should be given in diphtheria is not surprising ; that, how- 
ever, it should be given in a septic or gangrenous form is 
almost incredible ; that it should be recommended as a 
panacea in all classes and forms of diphtheria shows that 
common sense and sound judgment does not always pre- 
vail in the treatment of a disease where individualizing is 
of the utmost importance. If there be any specific in the 
world, mercury is not it ; not even in syphilis. However, 
not all cases of diphtheria are septic or gangrenous ; and 
not all cases occur during an epidemic ; nor are all the 
cases occurring during an epidemic of the same type. 
Some have the well-pronounced character of a local dis- 
ease, either on the tonsils or in the larynx. The cases of 
sporadic croup met with in the intervals between epidem- 
ics yield no constitional symptoms, and assume more the 
nature of an active inflammatory disease, very much like 
the sporadic cases of fibrinous tracheo-bronchitis. These 
are the cases in which mercury deserves to have friends, 
apologists, and even eulogists. Amongst them I shall 
not mention any of the old-time practitioners, who may 
have been led to the regular use of mercurial preparations 
in large doses by the very fact of their cases assuming the 
merely inflammatory character, but a few with a deserv- 
edly fair fame, and taking a high rank in the modern pro- 
fession. I shall mention Oppolzer, Bartels, Senator, and 
Rauchfuss, the two latter of whom are alive and still 
active ; but again insist on the fact that they use mercu- 
rials in membranous croup for its liquefying and melting 
effect. Of these, however, after long experience, Bartels 
discarded it; Oppolzer used calomel and iodide of potas- 
sium ; Senator, calomel and antimony ; Rauchfuss, calomel 
with oxysulphuret of antimony, blue ointment, and hypo- 
dermic injections of the corrosive chloride. 

In regard to the action of mercurial remedies, I am no 
longer so skeptic as I was a quarter of a century ago. For 



TREATMENT. 1 89 

a dozen years I hardly ever prescribed mercury, suppos- 
ing that the harm it might do could be avoided by substi- 
tuting other medicines, and that its effect, except in syphilis, 
could be obtained by other means. I admit that the expe- 
rience of many subseqent years has changed my views to 
a certain extent. I know that in chronic inflammatory 
troubles which I considered incurable in former times, a 
good many favorable results have been due, at my hands, 
to the protracted influence of mercurials ; thus, for in- 
stance, in chronic inflammations of the nervous centres, 
particularly the spinal cord. I also know that when the 
constitutional effect of mercury could be obtained speed- 
ily, cases of fibrinous tracheo-bronchitis got well in an 
unexpected manner. To accomplish that, it is neces- 
sary to give small doses very frequently. Calomel, 0.5- 
0.75 (grs. viij.-xij.), divided into thirty or forty doses, of 
which one is taken every half-hour, is apt to yield a con- 
stitutional effect very soon. Such doses, with minute 
doses, a milligramme or more (gr. -gL-), of tartar emetic, 
or ten or twenty times that amount of oxysulphuret of 
antimony, have served me well in fibrinous tracheo-bron- 
chitis. But the mucous membrane of the trachea and 
bronchi is more apt to submit to such liquefying and mac- 
erating treatment than the vocal cords. The latter have 
no muciparous glands like the former, in which they are 
very copious. And while the tracheal membrane is apt 
to be thrown out of a tracheal incision at once, though of 
more recent date, the pseudo-membrane of the vocal 
cords takes from six days to sixteen or more for com- 
plete removal. Still, a certain effect may even here be 
accomplished, for maceration does not depend only on 
the normal mucus of the muciparous glands, but on the 
total secretion of the surface, which will be in constant 
contact with the whole respiratory tract. Thus, either 
on theoretical principles, or on the ground of actual expe- 
rience, men of learning and judgment nave used mercury 
in such cases as I detailed above, with a certain conn- 



190 A TREATISE ON DIPTHERIA. 

dence. The actual benefit derived therefrom cannot have 
been great, for the mortality from croup has nowhere 
been encouraging. Nor is it an enjoyable proof of its 
efficacy that Bartels is known to have lost confidence in 
it in his ripest old age, either for its general unsatisfac- 
toriness, or for the reason that the general character of 
all the cases in the epidemics of his later years changed 
the nature of his cases from the inflammatory to the septic 
type. 

If ever mercury is expected to do any good in these 
cases of suffocation by membrane, it must be made to act 
promptly. That is what the blue ointment does not. In its 
place I recommend the oleate, of which ten or twelve drops 
may be rubbed into the skin, along the inside of the fore- 
arms or thighs (or anywhere, when their surface becomes 
irritated) every hour or two hours. Or refracted doses 
will be useful, such as given above ; or hypodermic injec- 
tions of corrosive bichloride in one-half (or one) per cent 
solution in distilled water, four or five drops from four to 
six times a day, or more, either by itself or in combination 
with the extensive use of the oleate, or calomel internally. 
The hypodermic injections act very promptly and favor- 
ably, as I repeatedly convinced myself; for instance, in 
those cases of hereditary syphilis, which, from the pres- 
ence of volar or palmar pemphigus and general cutaneous 
eruptions at birth, yield, as a rule, an almost fatal prog- 
nosis under ordinary circumstances, and with the ordinary 
treatment. 

ASTRINGENTS. 

It seems to me a fact worthy of notice that the pure 
astringents, as alum, tannin, and nitrate of silver, which 
are so extensively employed in the treatment of the simple 
pharyngeal catarrh, appear to have been given up, to a 
greater or less extent, by most practitioners, where an 
exudative process exists. Oertel raises an objection to 
the employment of astringents, on the ground that, by 



TREATMENT. 191 

hindering the detachment of the membranes, they are 
more likely to prevent suppuration, and thereby facilitate 
the impregnation of the tissues with poisonous elements. 
Whether this theory be correet or not, I assume that it is 
based on an experience which agrees with my own, as a 
result of which I am opposed to the employment of pure 
astringents. The remedy, however, which, for a number 
of years, has been employed by physicians, and which, 
furthermore, belongs to the group of astringents, is the 

CHLORIDE OF IRON. 

This substance was first used in diphtheria because an 
analogy was supposed to exist between the latter disease 
and erysipelas, in which the remedy had proved of great 
utility. It was introduced into France by Velpeau, into 
England in 1851 by Hamilton Bell in the treatment of 
erysipelas, and employed, not merely locally, but also 
internally. It has been used in diphtheria in France, by 
Gigot, since 1848, and in the following year by Crichton, 
in Scotland. Richardson, in the year 1865, published a 
report of two hundred and twenty cases of diphtheria in 
Melbourne, extending over a period of seven years, which 
he had treated without exception, since 1861, with large 
doses of the chloride of iron in combination with chlorate 
of potassium administered in the form of powder. There 
were eighteen deaths, constituting 8.2 per cent of the en- 
tire number of cases, in other words, a mortality but little 
greater than that from measles, as observed by himself and 
many others. Since that time, British and American 
journals have teemed with the reports of good results fol- 
lowing the administration of the chloride of iron, and in a 
monograph which appeared a few years ago, Schaller 
maintains that the diluted chloride of iron is superior to all 
other remedies in the treatment of diphtheria. I have 
used the chloride of iron in very many cases of diphtheria. 
In my essay on the latter disease, in i860, I spoke of its 
effectiveness after observing a large number of cases of 
the disease in 1858, 1859, an d i860. 



192 A TREATISE ON DIPHTHERIA. 

In the administration of the chloride of iron it must by 
no means be forgotten that small doses at long intervals 
are out of the question. I have not the least doubt 
but that the failure of the remedy may be attributed in 
most cases to the fact that the doses were too small and 
administered too seldom. Steiner thought himself in 
duty bound to refute Schaller's statement concerning the 
efficacy of the remedy after employing it for four chil- 
dren. He administered hourly a teaspoonful of a mixture 
containing five to eight drops of the tincture of the chlo- 
ride of iron in three ounces. In addition, a mixture con- 
taining thirty drops in sixty grammes was applied locally 
three or four times daily. The youngest two, one a child 
of three years, died in consequence of an extension of the 
process to the larynx, the other two recovered. 

These experiments were decidedly incomplete and 
therefore gave an unsatisfactory result. A dose of five to 
fifteen drops every ten or fifteen minutes, half hour, or 
hour, is indispensable for a proper estimation of its effects. 
Gargles are not of much service, for the simple reason 
that they do not come into sufficient contact with the 
affected parts, and reach at the utmost to the anterior 
pillars of the soft palate. A direct application of the 
remedy to the mucous membrane of the pharynx may also 
be desisted from, thereby avoiding any irritation, the in- 
ternal administration at short intervals causing the 
pharynx to be sufficiently influenced by local contact with 
the remedy. It must, of course, not be expected that the 
chloride will remove the membrane, but it can frequently 
be seen to reduce the hypersemia and swelling, and pre- 
vent the reproduction of exuded material. Now, as re- 
gards the power of coagulating albuminous substances 
which is possessed by astringents, a considerable difference 
between these various agents can be demonstrated. A 
solution of tannin brings about a cloud-like flocculus, car- 
bolic acid the same, but it requires to accomplish that effect 
about half a minute ; alum, a viscid coagulated mass which 



TREATMENT. 193 

sinks to the bottom of the test-tube without increase of its 
bulk by further deposits ; creasote, added drop by drop, 
forms isolated coagula, each one of which sinks separately 
to the bottom and increases in size. Perchloride of iron 
produces a coagulum several lines in thickness and sinks 
slowly to the bottom, while the fluid above remains clear 
(M. Putnam Jacobi). 

When we expose the subcutaneous veins in a living rabbit 
and touch them with a drop of solution of the chloride, 
no effects will be apparent for more than a minute. At 
the end of that time, the calibre of the veins becomes 
decidedly diminished ; on the other hand, a drop of 
creasote similarly applied gives rise to coagulation which 
at once obliterates the veins by compression. The effect 
in the latter case is purely mechanical. The former indi- 
cates that the chloride exerts a decided influence on the 
vital contractility of the blood-vessels. This increased 
contractility certainly assists in diminishing the rapidity 
of absorption of putrid fluids through the blood-vessels, 
which constitutes the principal source of danger from the 
disease. 

It cannot yet be positively asserted that the chloride 
of iron exerts a direct effect on the lymphatic vessels. 
Naturally this was claimed, when the remedy was trans- 
ferred from its therapeutic effects in erysipelas with the 
accompanying inflammation of the lymphatic vessels of 
the skin, to the treatment of diphtheria. Although we 
know of no direct compression of the lymphatic vessels 
due to the action of the chloride, yet it may be assumed 
that perhaps the compression of the blood-vessels exerts a 
similar influence upon the neighboring lymphatics. In 
consequence of this there would be an impediment to the 
absorption and further development of poisonous sub- 
stances in the lymph. The chloride, like the sulphate of 
iron, is a tolerably powerful disinfecting agent. All astrin- 
gents act more or less as disinfectants, and some of the 
best disinfecting agents, as creasote, are powerful astrin- 
13 



194 A TREATISE ON DIPHTHERIA. 

gents. .Mundy employed iron in the treatment of wounds, 
and Beale claims that it is a powerful antiseptic, especially 
when combined with glycerine. He explains its action on 
the ground of its limiting the growth of the bioplasm and 
hence checking the rapid necrobiosis. It is as efficacious 
in checking the movements of micrococci and bacteria as 
in coagulating albuminous ferments, so that its action may 
be explained to suit the existing theories concerning diph- 
theria. As the result of experiments with disinfecting 
agents, which were undertaken in London, it was found 
that 2.27 litres (half a gallon) of chloride of iron sufficed to 
disinfect 30,000 litres (6,600 gallons) of polluted water, 1.36 
kilogramme (3 lbs. avoirdupois) of chloride of lime, and 
36.35 lbs. of lime being necessary to produce the same re- 
sult. The chloride of iron long had a place in Chevallier's 
list of disinfectants, and is placed by Herbert Baker by 
the side of other mineral salts to which he attributes the 
power of destroying chemical poisons. 

The internal administration of the chloride of iron, 
moreover, is undoubtedly as important as its local appli- 
cation, even though the theory of its absorption, and of 
its action after absorption, be still involved in obscurity. 
It has been claimed that the chloride is decomposed 
immediately after it has been introduced, and that the muri- 
atic acid alone enters the circulation, but the urine has 
just as little revealed the presence of free muriatic acid as 
of the salt. There is reason to believe that the chloride of 
iron is absorbed with remarkable rapidity by the stomach 
directly, and that the re-appearance of the iron in the 
faeces may be explained by an elimination of the remedy 
by the intestinal glands. Moreover, Quincke has found 
that when the chloride of iron is rapidly introduced di- 
rectly into the veins of animals, emboli form in the pulmon- 
ary vessels ; but when the drug is so slowly injected that 
its entrance into the blood may correspond with the period 
required by the stomach for absorption, only very minute 
precipitates will form and be taken up by the white blood- 



TREATMENT. 195 

corpuscles. If this observation be correct, it may go very 
far toward explaining the action of the chloride of iron in 
septic diseases, which are accompanied by an exalted 
activity of the lymphatic vessels, and an increase of the 
white blood-corpuscles. Furthermore, Saase has in so far 
modified the general opinion concerning the influence of 
the iron and the obliteration of the blood that he attributes 
to the ferreous salts the power of converting oxygen into 
ozone. They share this power with the blood-globules 
exclusively, and could hence, to a certain degree, sup- 
ply a deficiency of the latter. Pokrowsky, too, has shown 
that iron increases the process of oxydation in the body by 
demonstrating that in health there is a elevation of tem- 
perature and an increase of the percentage of urea in the 
urine, during its administration. In anaemic persons, to 
whom iron has been given for the purpose of increasing the 
amount of blood, the above phenomena may be observed 
before this object is accomplished. Thus iron appears 
to replace the blood-corpuscles to a certain extent. Now, 
in infectious disorders of the blood, when the red gobules 
are perpetually menaced with destruction, it seems plausi- 
ble that the preparations of iron should exert an antiseptic 
action. 

Finally it has been found that of all the preparations of 
iron, the chloride possessed the power of stimulating the 
nervous system. Possibly this effect may be traced to an 
increase of the arterial pressure in the nerve-centres. It 
has been said that this effect has been vividly illustrated 
in certain forms of chlorosis. If this be true, iron would 
be all the more indicated in diphtheria, since it would act 
as a prophylactic against a series of nervous phenomena 
that so frequently present themselves, both during and 
subsequently to, the diphtheritic process. 

CARBOLIC ACID 

has long held a prominent position in the group of disin- 
fecting agents. It is an established fact that, in solutions 



I96 A TREATISE ON DIPHTHERIA. 

of the proper strength, it checks putrefaction, destroys 
bacteria, and suspends the movements of the white blood- 
globules. It is true we cannot infer from this that diph- 
theria depends on the presence of living germs which, in 
a state of health, exist in large numbers in almost all the 
organs of the body, the more so as an immense quantity 
of the disinfectant is shown above to be required for that 
purpose ; but carbolic acid exerts a powerful influence on 
the vitality of all living elements, and, hence, too, on rapidly 
proliferating epithelium which constitutes a part of the 
diphtheritic membrane. It has been experimentally 
proven that carbolic acid destroys the efficacy of vaccine 
virus ; in a similar manner, probably, it lays low the 
diphtheritic poison. I employ it both locally and inter- 
nally, the latter in frequently repeated doses — every ten 
or fifteen minutes to one hour — dissolved in water, with 
or without the addition of glycerine or alcohol, adminis- 
tering from one-half to two grammes (eight grains to half a 
drachm) in twenty-four hours. For gargles, mouth-washes, 
and nasal injections, I resort to solutions of one-half to two 
per cent. Rothe also has seen excellent results from the 
use of carbolic acid, and it forms an important part of 
many recipes highly recommended by contributors to 
medical journals. In the degree of dilution in which he 
has employed it, the results have probably been similar to 
mine with the use of more concentrated solutions, for he 
too describes the contraction and shrinking, though not 
the crumbling of the membrane which I have frequently 
seen to occur in a short space of time. He combines the 
remedy with iodine, for external applications, in the fol- 
lowing proportion: Carbolic acid and alcohol, each 2 
parts ; water, 10 ; tincture of iodine, 1 part. 

SALICYLIC ACID, 

of late, has been highly praised as a disinfecting agent. 
Its action is tolerably well understood, but continued 
observation and clinical experience will tend to cool 



TREATMENT. I97 

the ardent enthusiasm with which salicylic acid has 
been praised. I have not had favorable results from the 
local employment of salicylic acid. In rather concen- 
trated solutions (1 : 30-50) and in weaker strength (1 : 200- 
300) its action was alike undeserving of praise. In the 
more concentrated form it acts as a caustic ; the only 
effect that I could perceive from the milder solution was 
a diminution or total disappearance of the foul odor from 
nose and throat, but 1 cannot testify to a more rapid de- 
tachment of membrane, or to a more speedy termination 
of the disease under its use. Its failure to produce good 
results seems to me to be in direct proportion to the ex- 
tent and thickness of the membrane. Its salts are no dis- 
infectants, but antifebriles, and salts are at once formed 
in the stomach when it is given internally. Where there 
was high fever accompanied by a very moderate exuda- 
tion, I had reason to be satisfied with the effects of the 
drug administered internally. I have reference to cases 
in which the general symptoms are more prominent than 
the local ones, where the latter may even be absent, and to 
which, as long as twenty years ago, I applied the term of 
diphtheritic fever. One of my first cases on which I tried 
the salicylate of sodium was that of a boy of four years, 
who for days had a slight exudative deposit, a marked 
swelling of the glands of the neck, and a temperature of 
nearly 106 F., without showing any signs of improve- 
ment. The prognosis was rather unfavorable, or, to place 
it in the best light, very doubtful. Under the adminis- 
tration of 4-5 grammes (3-4 scruples) of salicylic acid, 
combined with 3 grammes (2]4 scruples) of bicarbonate of 
sodium daily, the boy recovered. My experience was 
similar in many other cases. In many, on suspending the 
remedy, the temperature would rise, but sank again as 
soon as it was resumed. For this reason I recommend 
the use of sodium salicylate as an antifebrile agent in a 
severe attack of diphtheritic fever, while I am not at 
liberty to speak favorably of the local action of salicylic 



I98 A TREATISE ON DIPHTHERIA. 

acid on parts covered with membranous deposits.* When- 
ever it is administered, however, it ought not to be forgot- 
ten that serious brain troubles, collapse, and irregular and 
paralytic breathing may follow its administration. It 
ought not to be used without careful watching, and the 
cotemporaneous free use of alcoholic stimulants. 

As regards the antiseptic action of the usual doses of 

QUININE, 

it can be hardly considered as brought about otherwise 
than by actual contact with the membrane, and not per- 
chance after absorption into the blood. Binz found, as the 
result of experiments with solutions of pure quinine vary- 
ing from one part in a hundred to one in a thousand, that 
the latter sufficed to prevent the development of bacteria 
in fluids capable of undergoing putrefaction ; but even 
estimated thus, a patient with eighteen pounds of blood 
would require one hundred and thirty-eight grains of 
quinine circulating therein in order to satisfy the condi- 
tions of Binz's experiment. If Binz considers two grammes 
(half a drachm) of quinine per day sufficient for an indi- 
vidual weighing one hundred and twenty pounds, his cal- 
culation is founded on experiments with dogs, in which 

* In regard to the effects of sodium salicylate, P. A. Blanchier made a num 
ber of experiments in Vulpian's laboratory (Recherches exper. sur Taction 
physiol. du salicylate de soude, Paris, 1879). His conclusions are as follows : 
It requires rather large doses to exhibit an effect. In the commencement it 
stimulates, and afterwards paralyzes the central nervous system to such a 
degree as to destroy the functions of the gray substance. By its effect on the 
nervous centres, and especially the medulla oblongata, it increases secretions, 
produces vomiting, and disorders the gastro-intestinal tract, and destroys life 
by paralyzing respiration and circulation. It has no influence on the peri- 
pheric, sensitive, or motory nerves, but paralyzes the sympathetic ganglionic 
cells in general, and the intracardial ones particularly. In very large doses it 
affects the glandular cells as well, as also, histochemically, the muscular tissue, 
though it cannot claim to be a muscle poison. Its therapeutical success in 
articular rheumatism is attributed to its local modification of the inflamed tis- 
sues of the joints, an attempt rather at an explanation than a lucid and intelli- 
gible illustration of its effect. 



TREATMENT. 199 

septicaemia was avoided by the injection of quinine. It is 
also necessary to bear in mind that Binz makes a distinction 
with regard to the preparations of quinine employed. He 
warns against the use of the bisulphate as being the most 
inactive. No matter which preparations are used — I pre- 
fer the muriate — I have come to look upon quinia as of no 
great service in reducing the temperature in infectious 
fevers. The main indication for its use can only be found 
in inflammatory fevers. When it is given, however, salicy- 
late of sodium may be added for a short time to obtain 
a speedier effect. 

My position in regard to the question whether the 
local manifestation of the disease, or local origin of 
the disease, should be treated with caustics, is at once 
determined by the fact whether in individual cases I 
consider the membrane the symptom of a general disor- 
der, or the cause of the disease. In the former case less 
can be accomplished than in the latter, supposing that the 
destruction of the morbid products can be accomplished 
at all. The matter is not by any means simple, for even 
though the membrane be but the result of a general pro- 
cess, yet the presence of membrane or of an infiltration 
acts in turn locally, by influencing the lymphatic system, 
by injuring the blood-vessels, and by contaminating the 
air, so that, what was an effect now becomes a cause. 
Therefore there is, at all events, a theoretical indication to 
destroy existing membranes, and thus render them innocu- 
ous. But in practice we often meet with either im- 
possibilities or contra-indications. Most of the caustics 
act only superficially ; this is especially the case with 

NITRATE OF SILVER. 

POTASSA 

and other deliquescent salts, as also 

CHROMIC ACID 

may at once be excluded because of their proving dan- 



200 A TREATISE ON DIPHTHERIA. 

gerous to the neighborhood. In my experience, concen- 
trated mineral acids penetrated no deeper than nitrate 
of silver ; for the quantity at each application must only 
be small. Indeed it is far easier to recommend than to 
carry out the cauterizing process. Few patients have 
enough self-control to permit a thorough application of 
the remedy, and rarely does it succeed so happily that a 
satisfactory effect is obtained, while at the same time — and 
that is of paramount importance — no injury is caused to 
the surrounding parts. Inasmuch as I so forcibly insist 
on the importance of keeping the oral mucous membrane 
as healthy as possible, and even for that reason alone look 
with favor upon the treatment by chlorate of potassium or 
sodium, I should certainly take great care not to cause 
wounds or erosions on which the diphtheritic process 
could at once take root. I consider it wrong to cauterize a 
membrane or infiltration unless I am sure of being able to do 
it thoroughly, and at the same time to limit the action of the 
remedy to the diseased surface. I prefer, above all other 
remedies for cauterization, a mixture of equal parts of 
carbolic acid and glycerine or the concentrated acid alone. 
I have occasionally seen good results therefrom. The 
local action is at all events satisfactory if it can be restricted. 
The membrane crumbles and drops off in small fragments. 
Where the oral or pharyngeal space is small and the 
patient unruly, I confine myself to frequent disinfection of 
the diseased parts with weak solutions of carbolic acid, 
by way of the mouth or nose. I never use force to compel 
a child to submit to a cauterizing process in the throat, 
when I mean to limit the effect of a caustic. Dr. A. Had- 
den recommends to me the local application of the liquor 
subsulphatis ferri. He states that in his opinion some of 
his tracheotomized patients recovered in consequence of 
the local effect it had on the tracheal membranes. 
My experience with 

bromine, 
administered internally at short intervals, in order to 



TREATMENT. 201 

combine local with general treatment, and employed in 
numerous cases in several epidemics, does not redound 
to its credit. To apply bromine in substance, or slightly 
diluted, to the affected parts, as I have seen others do, 
and have myself done in hospital gangrene, is here 
entirely out of the question. Therefore, solutions only are 
admissible, as recommended by Ozanam, Schiitz, Rapp, and 
others. I have given the remedy in one-half per cent solu- 
tion with bromide of potassium every half-hour or oftener, 
without being edified regarding the local or general effects. 
In a number of cases, I have preferably given the bromide 
in statu nascente by mixing chlorine water with a solution 
of bromide of potassium. It is a more agreeable mode of 
administering the remedy, although the effects are not in- 
tensified thereby. 

In this connection, however, I should feel remiss of 
fulfilling my whole duty if I did not refer to the favorable 
effects, claimed by as deserved a colleague as Prof. Wm. 
H. Thompson, for bromine both locally and internally. 
While in a number of cases I have carefully followed his 
plan of treatment, 1 cannot say that my expectations were 
fulfilled. Still, his convictions are so strong, and his field 
of observation so large, that I gladly avail myself of his 
permission to detail his treatment in his own words, as 
contained in the following letter of his : 

New York, Aug. 21st, 1880. 
Prof. A. Jacobi: 

Dear Doctor : — ... I will simply give my reasons 
for relying on bromine in diphtheria as follows : 

I have been led long ago, by experience as I fancied, to 
prefer the haloid disinfectants, i. e., chlorine, bromine, 
iodine, and sulphur, to the carbolic acid class, i. e., quinine, 
salicin, carbolic acid, camphor, the spices, etc., against the 
septic changes which the specific communicable acute 
diseases cause in the system. On the other hand, for in- 
fection by decomposed pus, etc., the carbolic acid group 
is superior to the haloids. Those conditions, however, 



202 A TREATISE ON DIPHTHERIA. 

which are more or less similar in their symptomatology, 
with low petechial or gangrenous manifestations, common 
in bad cases of measles, scarlatina, variola, typhus, and 
some cases of dysentery, as well as markedly in diphtheria ; 
in all such I regard the chlorine and bromine class far 
more effective. 

Of all members of this latter group of antiseptics, I have 
found bromine the most active and the best borne when 
administered according to the directions to be mentioned. 

It can be taken internally in relatively larger doses than 
any disinfectant with which I am acquainted, and from 
the entire absence of effect upon the nervous system 
(which cannot be predicated of any of the carbolic acid 
family, not even of quinine) it acts on the body purely as 
an antiseptic. Hence I have employed it for eighteen 
years in the treatment of diphtheria to the exclusion of 
all other remedies, and until I note very different results 
from it than has been the case in my own practice, I shall 
use no other remedy whatever. 

The benefits I would claim to result from its proper ad- 
ministration in diphtheria are these : 

i. When applied locally, it promptly arrests fetor by 
arresting directly the gangrenous process, and thus lessens 
risk from absorption. 

2. It acts as an anti-putrefactive likewise in the fluids 
of the body generally, i. e., blood, interstitial circulation, 
and secretions, owing to its high rate of diffusibility, 
equal to sodium chloride itself. 

3. It locally destroys the communicable property of the 
discharges, shown by the immunity of attendants from 
any sore throat, when it is used, and from its checking the 
spread of the disease in the locality. 

No claim can be adduced for it as an antidote, so-called, 
to the diphtheritic agent, except that I believe it can 
wholly destroy its germs when they are locally developed 
previous to general infection. When reproduction through- 
out the body has occurred, or when the contiguous 



TREATMENT. 203 

lymphatic glands are extensively infiltrated, its action is 
then simply that of an internal antiseptic, and as such, I 
think, has no superior. 

When called to a case, I order two solutions to be used ; 
the first of equal parts of Lawrence Smith's solutio 
bromini and glycerine, applied with a hair pencil to the 
membrane, as gently as possible. Sometimes I use the 
solution full strength. The brush should be washed at 
once in water, and does not last more than one day, owing 
to the action of the bromine on hair. If, however, the 
membrane be very extensive and the parts much swollen, 
or difficult to reach, I resort instead to douching with a 
Davidson syringe, using half a drachm to one drachm of 
the solution to the pint of warm water. By beginning 
gently with the stream directed against the buccal mucous 
membrane, the child soon becomes accustomed to the cur- 
rent and allows it then to play against the deeper parts. 

Internally I order from six to twelve drops of the solu- 
tion to half-ounce of sweetened water, every hour, two, or 
three hours according to the urgency of the case, and 
continuously ; no other medicine being taken until the 
disappearance of the membrane ; when the case may then 
be treated on general principles. For convencience' sake 
I frequently order the preparation : 3 Smith's sol., 3 i. ; 
Aq., 3 i. ; teaspoon in tablespoon of well sweetened water. 
It should be swallowed promptly, for the disagreeableness 
of bromine is due much more to its fumes than to its taste, 
and patients soon learn to take it readily. The only in- 
convenience which I have seen from it has been in some a 
slight looseness of the bowels, which may be readily con- 
trolled by a small dose of paregoric. It is well borne by 
the stomach, as I have repeatedly seen it retained when 
solutions of quinine, or tr. ferri were uniformly rejected. 
The only diet recommended is cold milk and lime-water. 

As to the amount which may be taken with impunity, 
I once saw, in consultation with Dr. Chauveau, of Houston 
street, an infant of fourteen months, whose case seemed 



204 A TREATISE ON DIPHTHERIA. 

hopeless from laryngeal extension of the membrane, but 
for three days it took twelve drops of Smith's solution, 
equivalent to two drops and a half of pure bromine, every 
hour unintermittingly, and finally recovered without an 
untoward symptom. 

The most convenient way of making Smith's solution is: 
take two ounces of a saturated solution of potass, bromid. 
in water, add to this, very slowly, in a bottle and with 
constant shaking, one ounce of bromine. It is better to 
add a part and then let it stand a while before adding the 
rest ; then fill up gradually, and with constant shaking, with 
water till it measures four ounces. This solution should 
be complete and without sediment. Dose, as above stated, 
six to twelve drops in well sweetened water. But it 
should not be ordered in a mixture with either glycerin or 
sugar, for it is soon changed by these agents into a color- 
less compound which is certainly inefficacious. For daily 
use I order it as above stated, dissolved in different 
strengths in simple water, and if not exposed to too strong 
light, it keeps for several days. Yours sincerely, 

W. H. Thomson. 

Finally, I reproduce (from Prag. Med. Woch., No. 10, 
1880) an abstract of the treatment which J. Schiitz recom- 
mends. It is a bromine treatment, similar to that which 
he eulogized ten years ago, and which, amended by what 
I cannot help believing doubtful practice, he applied to 
twenty-eight cases with, as he states, satisfactory results. 

As soon as a deposit is visible in the throat, the finger 
is covered with a piece of linen cloth, moistened with 
water, and the membrane rubbed off.* When it is but 
partly removed, the process is repeated. " Patients felt 
better immediately, were cheerful, fever diminished, appe- 
tite increased, and sleep was no longer disturbed." After 

*Also E. J. Bonsdorff (Hygeia, No. 4, 1879, Med. Rec, Sept. 20th) takes 
the responsibility of mechanical removal, by all means possible, of the exuda- 
tion and mortified tissue, and touches the surface with nitrate of silver, twice 
daily " if necessary." 



TREATMENT. 205 

the membranes were rubbed off, he made two or three injec- 
tions of a solution of bromine and potass, bromid., aa i , in 200 
parts of water, or of pure water. That forcible removal of 
membranes must be repeated two to three times daily. The 
injections are to be repeated hourly. " Advanced chil- 
dren take a great pleasure in making the injections them- 
selves." (?) " The parts injured during the rubbing-off 
process remain mostly intact." (?) When there are obstin- 
ate membranes, they ought to be moistened with bromine 
solution five or six times daily. Cold applications round 
the neck are not required. Glandular swellings require 
pot. iodid. ointment (1 14), the size of a pea, three times 
daily. (?) "The patient is isolated. As a matter of pre- 
caution, after recovery, the bedding is aired, and it is 
left to the attendant to resort to any kind of disinfec- 
tion." (!) 

Jaeger (Corr.-Bl. f. Schweizer Aerzte, 1877, No. 5) uses 
iodide of bromine, potass, brom., aa 0.3-0.5 ; aq. destil., 150.0 
(gr. v.-viij. in water § v.), |— 1 teasp. hourly or half-hourly 
for inhalation. Ice in addition. Netolitzky (Prag. Med. 
Woch., 1879, J une 2 3d), potass, brom., bromin., aa 0.05- 
1.0; 150-200 (gr. i.-iss. in § v.-vi.) to be inhaled from a 
sponge for five or ten minutes every hour. Prince (St. 
Louis M. J., 1877, July 18th) prefers, also for inhalation, 
iodin., 0.06; potass, iod., 0.25 (gr. i.-iv.), in a mild solution. 

OZONE 

has but recently been recommended again, this time by 
Ph. Jochheim (Darmstadt, 1880). It is developed in 
a Richardson's apparatus, with two tightly-fitting corks 
and a funnel, by slowly (drop by drop) adding concentrated 
chemically pure sulphuric acid, 30.0 ( 1 i.), to potassium 
hypermanganate, 30.0. Ozone is developed while hyper- 
manganic acid and manganese hyperoxyde are formed, and 
expelled by a common syringe balloon, the tube of which 
enters the apparatus by the perforated cork. Potassium 
iodide paper has to turn purple or bluish-black by it. An 



206 A TREATISE ON DIPHTHERIA. 

inhalation of three or five minutes every hour or two is 
considered sufficient. 

Still he does not neglect other treatment. Locally he 
uses a two or three per cent solution of potassium hyper- 
manganate as a gargle, mouth-wash, or application ; 
internally quinia muriate, 0.03-0.12 (gr. ss.-ij.), in honey or 
wafer, every two hours. Steam is used besides, and as a 
disinfectant, potass, hypermang., 50.0, in water, 300.0 (1 :6), 
mixed slowly in a china vessel with pure concentrated 
sulphuric acid, slowly heated. 

BORIC ACID 

has been used and eulogized by Wertheimber as a gargle, 
in a solution of 10 : 300 or 250, which is to be used every 
hour, with the exception of the nights, where the intervals 
may become longer. If gargling be inconvenient or re- 
sisted, the solution is injected, or the nasal douche resorted 
to. M. Vogel (Allg. Med. Centr. Z., Nos. 99 and 100, 1876), 
brushes the throat arid gargles with ac. bor. 4-6 : 180, 
every hour in the commencement. 

My own experience is not gratifying ; it is true that I 
gave up the remedy after I had used it in a dozen cases, 
but my results did not appear to encourage me. 

J. T. Lewis (Brit. Med. Jour., Jan. nth, 1879) recom- 
mends sulphurous acid in water as a gargle, in combina- 
tion with plenty of plain food and also stimulants. 

Concentrated solutions of boric acid have been highly 
praised in diphtheritic conjunctivitis. It is to be applied 
hourly. 

In accordance with Graham's experiments, made in Prof. 
Klebs' laboratory, which appeared to show that a certain 
proportion of 

SODIUM BENZOATE 

prevented the vegetation of the diphtheritic contagion, 
L. Letzerich (Berl. klin. Woch., Feb. 17th, 1879) adminis- 
tered sodium benzoate in twenty-eight cases, part of which 



TREATMENT. 207 

were serious. Of these twenty-eight, but one died, and 
that was a case of laryngeal diphtheria. The child had 
suffered from croup before, and retained a great tendency 
to laryngeal disorders. Infants of a year or under, took 
one-half tablespoonful hourly of the following mixture : 

1$ Sod. benz 5.0 (3iv.) 

Aq. destill., 

Aq. menth. pip aa40.o(|i. 3 iij.) 

Syr. cort. aur 10. o ( 3 iiss.) 

Children of from 1-3 years took 7.0-8.0 daily ( 3 ij.) 
children of 3-7 years, 8.0-10.0 (.3 iiss) ; and those over 7, 
sod.' benz. 10.0-15.0 (3iij-?ss.). Adults took 15.0-25.0 
( I ss.-3 vi.) daily. A disagreeable effect was not noticed. 
Twice or three times daily, or in bad cases every three 
hours, sodium benzoate was thrown or blown upon the 
diphtheritic deposits. Older children would also gargle 
with a solution of 10.0 : 200.0. In all cases the fever de- 
creased within twenty -four or thirty-six hours. 

Amongst the first who tried sodium benzoate exten- 
sively was Demrae (Annual Rep., 1878). His doses were, 
for the age of 3-6 months, 2.5 daily (3)ij.); 7-12 months, 
5.0 (3iv.); 1-2 years, 7.5 (3ij.); 3-7 years, 12.0-15.0 
( 3 iij.-l ss.). In no case did he see an injurious effect. 
Beside the internal administration, he blew the drug 
into the throat every two or four hours. When the pro- 
cess was a very rapid one, with large tumefaction of the 
neck and glands, he also made subcutaneous injections of 
sodium benzoate (1:2) into the subcutaneous tissue and 
also into the tonsils. Besides, the trunk was treated with 
cold packs, and sometimes cold bathing was resorted to 
when the temperature was above 102 ; in septic cases 
also alcohol 5.0-75.0 (3iv.- § iiss.) daily. His mortality of 
twenty-two per cent he claims as favorable, though it does 
not impress me as such. To lose six cases out of twenty- 
seven is a result no practitioner is apt to rejoice over. 
Still he insists upon the following points as reliable con- 
clusions : 1st. That sodium benzoate is a reliable antizy- 



208 A TREATISE ON DIPHTHERIA. 

motic in both internal and external administration. 2d. 
By its local application both as a powder and in solution it 
increases the secretion of the mucous membranes and favors 
the removal of diphtheritic deposits. 3d. Even large doses 
do not reduce the temperature to any great extent. 4th. 
The contraction of the heart becomes more intense, the 
beats less frequent, and the secretion of urine more 
copious. 5th. It does not influence either nephritis or 
albuminuria. 

In regard to its effects as a medicinal agent, I never ex- 
pected much. The parasitic school of pathologists have 
been remarkably hasty in their literary productions, as is 
well known. The journals of the last ten years are flooded 
with superficial observations, insufficient experiments, and 
immature conclusions. " Preliminary communications " 
of any length, and long articles, at the close of which 
the very writer says that his experiments prove nothing 
(compare, for instance, Miflet in F. Cohn's Beitr., III., 
1879), abound. Thus journalism, and mainly in regard to 
those branches which boast of being exact, has become 
rather flimsy and flighty. The worst feature of this 
tendency in medical literature consists in the fact that the 
men who have to rely on their senses mostly, in their 
special investigations — mostly microscopical — finally rely 
on their own senses only. When they see benzoate of so- 
dium destroying bacteria in a glass vessel, they not only 
take it for granted that bacteria are the infectious disease, 
but also that the human organism will permit of the same 
action on the part of the antiseptic medicine as the glass 
vessel. Thus benzoate of sodium is sent into the stomach, 
or into a pulmonary cavity, under orders to do the same 
thing it does in the laboratory. The drug has, in conse- 
quence, had a short life, after having been extolled in a 
very limited time by microscopists, Russian diplomats, and 
the public in general. Clinicians tried it, but have soon 
learned not to trust it much. I believed I saw some favor- 
able result in puerperal diseases, at first, but do not feel 



TREATMENT. 209 

convinced in regard to them at all. As an anti-diphthe- 
ritic, or even as an anti-febrile remedy, it cannot be trusted. 
Fr. Mosler's general principles in regard to the treat- 
ment of diphtheria are those of all sound practitioners. 
Thus he avoids depletion, antiphlogistics, and emetics, 
particularly antimony, and prescribes nutritive food and 
medicines. As a local application he employs oil of turpen- 
tine in inhalation, after having given up carbolic and 
salicylic acids, and potass, hypermanganate, because of 
bronchial irritation resulting from their use. After he 
obtained a favorable result from the use of 

OLEUM EUCALYPTI E FOLIIS 

(not ol. eucalypti australis, which is lower in price) in a 
case of echinococcus of the lungs, he also employed it in 
diphtheria. His strongest formula is as follows : 

1$ 01. eucal. e fol 5-o(3iv.) 

Spir. vini rectif. 25.0 ( 3 vi.) 

Aq. destill 170.0 ( § vi.) 

M. For ten inhalations, one every hour or one and one- 
half hours. 

The professor hopes that no bronchial irritation will 
result from these inhalations, but admits that it may. His 
own cases are not numerous, and his confidence is not great. 

As in every disease which, at least in certain instances, 
presents great and insurmountable difficulties, so too in 
diphtheria, the pharmacopoeia has been ransacked for 
remedies. Long before the time of Roger and Barbosa, 

SULPHUR 

had been used. The insufflation of the drug at first gave 
rise to coughing and vomiting, and in the end proved dis- 
agreeable and futile. Still, Stuart (Practit., April, 1879) 
recommends it again. 

THE BALSAMICA, 

copaiba and cubeb, have been recommended for internal 
14 



210 A TREATISE ON DIPHTHERIA. 

administration, mainly by the French. Trideau's treatment 
of the inflammatory stage (not the septic) of diphtheria 
is so formidable that he was sure to have successors, if 
not successes. His doses of cubeb powder are for a 
child of from eight months to a year, 8.0 (3 ij.) daily ; of 
from two to three years, 10.0-15.0 ( 3 iiss.- 3 ss.) ; for an 
adult, 25.0-30.0 ( 3 vi.- 3 i.). Roger and Bastian opposed 
its administration because of its dangerousness, and 
mainly because of the difficulty of taking or giving 
it, and of the certainty of disordering digestion, which 
deserves of the greatest consideration wherever re- 
covery is, as frequently in diphtheria, depending on 
the power to resist the debilitating influence of the 
disease. Sanne opposes the use of balsamics, because of 
their being liable to produce nephritis, temporary though it 
may be. M. Larue (Gaz. Hop., 1877, No. 1 12) followed Tri- 
deau, however, adding quinia to obviate or relieve fever. 
Vedrini (Gaz. Med., 1878, July 27th, Aug. 3d) saw "great 
relief to children over ten years, in serious cases even," 
when he gave cubeb (12.0 [ 3 iij.] daily), and lost six out of 
ten. Others have given it, and what is worse still, recom- 
mended it. The objection to it, that it deranges digestion, 
is a very valid one, indeed, and Sanne is not correct when he 
believes the nephritis following the inordinate use of bal- 
samics to be but temporary. Smaller doses than those 
ordered above are well known to produce permanent 
nephritis ; unfortunately the opportunity to observe such 
cases is not so uncommon where diseases of the genito- 
urinary organs, in which the drugs of that class are so 
often used, are of frequent occurrence. Vaslin gave cubeb 
in 20.0 gramme ( 3 v.) doses daily in mild " anginas," and 
in thirty-four cases of croup. Of his eight cases of diph- 
theritic pharyngitis, one died of paralysis. Of the thirty- 
four cases of croup, three recovered without, ten with 
tracheotomy. This is high praise for tracheotomy, none 
for cubeb. 

T. M. Lownds (L. Lancet, 1879, March 22d) recommends 



TREATMENT. 211 

tr. perchlor. ferr., 3 iij.-iv.; sol. ac. ammon., 3 iss.-ij.; pot. 
chlor., 3 i.-iss. ; aq., f, 3 viij., tablespoonful every hour. 

D. de Berdt Hovell (L. Lancet, Dec. 28th, 1878) com- 
mences his treatment with a dose of calomel. 

A. Erichsen (Petersb. Woch., 1877, No. 4), hydrargyr. 
cyan., 0.0006 (gr. y^-) to children under three years, 0.0012 
(gr. -gL) over three years, every hour ; every two hours dur- 
ing the night. He did not succeed in losing more than 3 
children out of 25. 

Collin (Rev. ther.. 1876), no cauterization, no depletion, 
but good nutriments. Aq. calc, 120.0-360.0 ( § iv.-xij.) ; 
liq. ferri chlor., 20.0-40.0 ( 3 v.-x.) ; ac. carbol., 0.06-0.12 
(gr. i.-ij.). 

Anthony (Med. Surg. Rep., 1877, J an - ! 3 tn )' s °d. sulph. 
carbol., 3 ij. to a child of seven years. 

M. G. Sloan reported to the Iowa State Med. Soc, Jan. 
27th, 1880 (Med. Rec, Feb. 21st, 1880), 34 cases of diph- 
theria treated successfully with quinine in large doses, alter- 
nated with sulpho-carbolate of sodium. He used locally 
tinct. ferri. chlor. and glycerine, applied gently to the 
affected parts, and in four cases of laryngeal complications 
he cured three by the use of inhalations of lime-water with 
the constitutional remedies named. 

D. McFalls (Med. Rec, Jan. 24th, 1880), Lugol's solu- 
tion thickened with tannic acid to the consistency of thin 
cream, as a local application. 

Peyrot (Gaz. hebdom., Oct. 17th, 1879), bromide pot., 
15-20 (|ss.-3Y.); aq., 100 ( § iij.), as a local application, 
also brom. pot., undissolved for the same purpose. 

Hagenbach (Child's Hosp. at Bale, 16th ann. rep., 1878), 
ice internally, and externally inhalation of aq. calc, a solu- 
tion of sod. salicyl., lactic acid, or pot. chlor. A separate 
room filled with steam, zinc chlor. upon the tracheotomy 
wound. Emetics but rarely. 

T. Kaatzer (Berl. klin. Woch., 1877, No. 46) recommends 
still cauterization with the solid stick on three consecu- 
tive days, and pot. chlor. 10:300, a tablespoonful every 



212 A TREATISE ON DIPHTHERIA. 

■hour, gargling with the same solution, and ice exter- 
nally. 

Fehr (Deutsch. Z. f. prakt. Med., 1877, No. 25) gargles 
with sod. chlor. (on the meat-pickling principle) and carbon, 
sod. 1 : 150, a tablespoonful every hour, for the reason that, 
according to Tiegel, bacteria and micrococci are destroyed 
more easily by sod. carb. than other salts. 

H. Beyer (Brit. Med. Jour., 1878, May 4th), inhalation 
of a lactic acid solution. 

H. Roger and Peter (Un. Med., No. 100, 1877), in mild 
cases emetics ( ! ), ipec, 0.2-0.8 (gr. iii.-xii.) ; syr. ipec, 30.0 
( 1 i.), teaspoonful every 5 minutes, brushing of the mouth 
with lemon juice, twice daily irrigation with borax, alum, 
or aq. calcis. In serious cases repeated emetics ( ! ! ), syring- 
ing with aq. calc. 4-8 times daily, brushing with caustic 
soda 25 : glyc. 100, or arg. nitr. 10: 30 water. 

Bartels : ice, pot. chlorate, insufflation of alum or tannin, 
steam inhalations. 

Kidam : inhalations of whatsoever kind, if but warm and 
moist, warm poultices, pot. chlorate gargles. 

H. Zeroni (Memorab., No. 4, 1879), depletion and poul- 
tices. 

Kingford (L. Lane, No. 17, 1879), f° r more than twenty 
years, liq. ferr. mur., pot. chlorate, glyc. and water, every 2 
or 3 hours, two daily applications of tr. ferri and glycerine. 
Food and stimulants. 

A. Schuster, no specific remedy, no antiphlog., but 
robor., stimul., and symptomatic treatment. Quinia, ether, 
brandy, camphor, pot. chlor., aq. calc, ice. 

John H. Gilman (Med. Rec, Sept. 20th, 1879), locally 
once or twice daily ac. carbol., gtt. xv. ; tr. ferri chlor., 
3 iv.; aq., 3 iv. Internally, hourly through the day, pot. 
chlor., 3 iss.; aq., § iv.; ac. mur., gtt. x. A teaspoonful. 
In worse cases, pot. chlor., 3 iss.; aq., 1 iv.; tr. ferri chlor., 
3 ss.~i.; quin., gr. ij.-v., teaspoonful every hour, spray or 
gargle of liq. sod. chlorin. 

v. Rokitansky (Allg. M. Cent. Z., Med. Rec, July 12th, 



TREATMENT. 213 

1879), chloral and water, aa, brush every half-hour. 
Milder solution when the membr. has disappeared. 

F. L. Hartmann (Med. Rec., Jan. nth, 1879), chlorine 
in solution, sustaining diet, gargles of pot. chlorate, alum, 
salicylic acid, syr. ferri iod. 

F. A. Hubbard (Med. Rec, Nov. 15th, 1879), s °d. hypo- 
sulph. and pot. chlor., aa § ss.; may be dissolved in 
water as required for gargle, spray, internal use. Tully's 
powder, quinia, brandy, hot fomentations, or camphorated 
oil over swollen glands. In laryngeal diphth., vapor of 
lime in hot water from a coffee pot. 

M. J. Gahan (Med. Rec, Jan. 18th, 1879), tr. ferri mur., 

1 i.; pot. chlor., 3 ij.; aq., 5 vij.; gargle 4 or 5 times a day ; 

tr. ferri mur., 10-20 drops every two hours. Thus in 200 

cases, " it has yet to fail me — when " the disease was taken 

at its onset. 

E. Wiss (Deutsche Z. f. prakt. Med., No. 34, 1878), 
sulphate quin., 0.4-0.6 (gr. vi.-x.) ; aq. destill., 90.0 ( 3 iij.) ; 
ac muriat. dil., gtt. iij.; ammon. mur., 6.0 ( 3 iss.) ; syr. 
cort. aurant., 30.0 (f i.); |— 1 teaspoonful every two hours. 
No death (any patients ?). 

3ouffe, no pot. chlor., no alkali, no emetics for exter- 
nal use. Every two hours ointment of axung, 75 ; camph., 
25 ; tr. benz., 4-8. For internal use every hour a tea- 
spoonful or one-half tablespoonful of : lemon juice, 300 ; 
sod. chlorid., sod. sulphate, aa 10 ; honey, 15 ; with the addi- 
tion of some sod. carbonate. In the intervals, flax-seed tea, 
gargling, milk, touch the lips often with the mixture, keep 
the neck and chest warm, do not cauterize, ice, soups and 
bouillon. In albuminuria, milk with or without soda. 

Wm. A. Reiter (A Monograph on the Treatment of Diph- 
theria, Philadelphia, 1878), calomel and pot. Somebody 
is credited on page 29 with " Pittsburgh children are hard 
to kill." 

J. Dubrisay (Gaz. Hop., 1877) still writes against the 
extensive use of tart, emetic. 

H. Helmkampff (D. Z. f. pr. Med., No. 37, 1877), ice 



214 A TREATISE ON DIPHTHERIA. 

internally and externally ; after three or four days, inhala- 
tion of steam, disinfection of oral cavity by mild solutions 
of carbolic acid; roborants. For swelling of submaxillary 
region a two-per-cent solution of carbolic acid hypodermic- 
ally. 

Taube (Jahrb. f. Kinderh., XIV., 1879, P- 20 9) : injection 
into the tonsils of a three-per-cent solution of carbolic acid, 
frequent injection into the nose, and sprays. Borax is 
preferred to turpentine, after this had been eulogized a year 
before. Local application in the night also. At 103 , 
quinia, a warm bath three times a day with cold shower. 
Frictions with alcohol. Cold applications around neck 
every half-hour. Cold pack every hour. No cauterizing. 
Milk and wine. Windows open. No draught. 

MECHANICAL REMOVAL OF THE MEMBRANES 

is not permissible unless they are almost entirely detached. 
As a rule, it is best to wait quietly till they are completely 
detached and cast off or swallowed, unless partly loosened 
membranes in the larynx or trachea afford an indication 
for an emetic. F. Barker alone has been fortunate enough 
to be able to claim that, with the assiduous and exclusive 
employment of turpeth mineral as an emetic, he has never 
had a death from croup of the larynx. Forceps requires 
very delicate manipulation, as any scratching or eroding 
of the neighboring mucous membrane increases at once the 
area of diphtheritic deposits ; sponges and brushes merely 
remove some superficial coating of the membrane without 
detaching the latter. Even where the membrane has been 
thrown off spontaneously, a new one often appears in a 
few hours. After a mould of the trachea and its bifurca- 
tion had been cast off, in a certain case — death occuring 
seven hours later — an autopsy revealed the presence of a 
thick membrane at the seat of bifurcation. Furthermore, 
the reports of good results from attempts at removal of 
local deposits are occasionally to be received with great 
care, particularly when they have reference to the larynx. 



TREATMENT. 21 5 

Undoubtedly camel's-hair brushes and sponges may be 
thrust down, and in fact membranes removed by them, 
but in very small quantity compared with that which still 
remains. At all events, I should not expect good results 
from such practice in cases of membranous deposits in the 
larynx. Perhaps still less here than elsewhere. For 
after tracheotomy, the tube can never be removed before 
at least a week has elapsed after the performance of 
tracheotomy ; I have never succeeded in doing without it 
before the seventeenth day in my own cases. Besides, 
the examination of membranes in the cadaver demon- 
strates that they have nowhere a more tenacious hold than 
in the larynx. What success then can be hoped for from 
attempts at a mechanical removal from that locality? 
The difficulty I have sometimes met with in my attempts 
at partly clearing the nasal passages by mechanical efforts 
makes me hesitate to put much faith in a mechanical clear- 
ing out of the larynx. 

THE TONSILS. 

In mild cases of diphtheria of the tonsils I at times en- 
deavor to destroy the membrane, but only when it can be 
reached with ease. In my opinion, the indiscriminate use 
of mineral acids and lunar caustic have done more harm 
than good. Where I can easily reach the membranes, I 
usually apply concentrated carbolic acid ; where the mem- 
branes are not entirely within reach, I desist from this pro- 
cedure. A scratching of the mucous membrane and a 
wounding of the epithelium would assist in spreading the 
membranous process in a very short time to the surround- 
ing parts. I have already discussed the tendency of the 
disease to extend rapidly, and the danger of creating fresh 
wounds. In most cases of simple tonsillar diphtheria, I 
administer small doses of chlorate of potassium or sodium 
in water, or the tincture of the chloride of iron, so that 
from two to eight grammes ( 3 ss.— ij.) are taken in a day. 
I add a little glycerine, partly for the sake of keeping the 



2l6 A TREATISE ON DIPHTHERIA. 

remedial agent longer in contact with the diseased sur- 
face, partly for its own antifermentative effects, and give 
it in short intervals. The accompanying fever is usually 
not high, and the neighboring glands are as a rule but little 
swollen or not at all. When there is a slight 

SWELLING OF THE LYMPHATIC GLANDS, 

cold water or ice applications are usually all that is 
needed. The latter should be made according to general 
indications. The glandular (and peri-glandular) swellings 
are less the result of an actual filling-up with foreign 
matter than of secondary irritation. Ice has a happy 
effect in such cases, both on internal administration, in the 
form of frequent small quantities of ice-water, ice-pills, 
ice-cream, and iced medicaments, as also externally by ice- 
cold cloths, or india-rubber bags filled with ice. 

In general, the treatment of the swelled glands must be 
both based on its causes, and adapted to the present con- 
dition. The adenitis and periadenitis is of secondary 
nature, the irritation being in the mouth, pharynx, and 
nares. In these localities it is where the main treatment 
is required. The sooner the primary affection is removed, 
or relieved, or rendered innocuous, the better it is for the 
secondary complaint. Frequent doses of chlorate of 
potassium, or sodium, or biborate of sodium (or benzoate ?) 
in mild doses frequently repeated, according to the prin- 
ciples laid down in another part of this book, mouth 
washes, gargles, nasal injections with water, salt water, or 
solutions of disinfecting substances are not only indicated, 
but highly successful. When the case is recent, cold ap- 
plications are required, but no washes. When it is of 
older date, stimulant embrocations are in order. Iodine 
ointments are absorbed but slowly ; mercurial plasters do 
good in some cases ; iodide of potassium dissolved in 
glycerine (i : 3-4), frequently applied, iodine in oleic acid 
(1 : 8-12), iodoform in collodion or flexible collodion 
(1 : 12-15) applied twice daily, the latter frequently with 



TREATMENT. 21? 

very good result, are beneficial. Copious suppuration is 
very rare. Cases in which a free incision meets with an 
abscess ready to heal are very uncommon. But local 
abscesses in large numbers, with gangrenous walls and 
pus mixed with a sero-sanguinolent or sero-purulent liquid 
are more frequently found. In such cases, a probe intro- 
duced into the lancet wound enters easily into the broken- 
down tissue in every direction, on slight pressure, to a 
distance of three to six centimetres (several inches), 
according to the size of the tumefaction. I have seen 
fatal hemorrhages from such gangrenous destructions ; 
therefore, the treatment must be both timely and en- 
ergetic. The incision must not be delayed too long. 
When the skin assumes a purplish hue, or is simply dis- 
colored, it is time to incise, and apply concentrated or 
nearly concentrated carbolic acid to the interior unless 
the neighborhood of very important blood-vessels or 
nerves yields a contra-indication to concentrated applica- 
tions. In that case, a milder preparation is advisable, but 
the application should be repeated often, until the suppu- 
ration becomes more normal. Then mild disinfectant in- 
jections into what has now become a cavity will be found 
satisfactory, particularly when meanwhile the general con- 
dition of the patient has been improved. 

DIPHTHERIA OF THE NOSE 

results either from an extension of the morbid process from 
the pharynx, or occurs primarily. It occasionally manifests 
itself by a peculiar, thin, flocculent discharge, not neces- 
sarily copious, and at times even trifling, and very often 
by a very early swelling of the glands of the neck, es- 
pecially those behind and beneath the angle of the jaw. 
Nasal diphtheria often occurs where the nasal mucous 
membrane has for a long time been the seat of catarrh. 
Especially during the prevalence of an epidemic of diph- 
theria must we be careful not to allow a nasal catarrh to 
have its own way ; we must likewise guard against con- 



218 A TREATISE ON DIPHTHERIA. 

sidering the thin and flocculent discharge in infected 
cases as a mucous secretion. Whatever be the origin of 
nasal diphtheria, whether primary or the result of a simi- 
lar affection in the throat, local treament should at once 
be instituted, and if this be done, the great majority of 
cases will terminate favorably. The danger in this form 
of disease consists in an excessive absorption of putrid 
substances, and in the breathing of contaminated air. 
The indications for treatment are clear and decisive. 
The interior of the nasal cavities must be thoroughly 
cleaned and disinfected. If this be commenced early, 
the original seat of the affection may be reached, and the 
disinfectant process will, as a rule, have good results. It 
is not necessary to select very energetic disinfectants ; 
a solution of twelve to twenty-five centigrammes (two 
to four grains) of carbolic acid in thirty grammes (an 
ounce) of water is at once mild and effective, and hardly 
gives rise to more discomfort than luke-warm water. 
Nasal injections must be made very frequently, until each 
time the stream of fluid has a free exit through the other 
nostril or through the mouth. They must be made at least 
every hour, and even oftener if necessary ; at the same 
time it is advisable to be careful that the fluid does not 
enter the Eustachian tube. This can be prevented, to a 
certain extent, by compelling the patient to keep the 
mouth open during the procedure. I have seldom seen 
evil, or only disagreeable results from the administration 
of nasal injections in diphtheria. Still, a medical friend 
assures me that he has seen convulsions to follow an in- 
jection, an occurence I never met with. It is likely that 
the mucous membrane of the pharynx is swollen as far 
as the openings of the Eustachian tubes, to such a 
degree as to render the entrance of fluids into the 
latter improbable. The hardness of hearing, whichisof so 
frequent occurrence in the course of a severe catarrh or 
diphtheritic attack, seems to indicate that the mucous 
membrane of that part is in a state of swelling. An or- 



TREATMENT. 219 

dinary syringe will suffice. However, when administered 
by parents or nurses, the blunt nozzle of an ear syringe or 
nasal douche is preferable , furthermore, by using the lat- 
ter, the distribution of fluid is more equal. Occasionally 
here, as in local applications to the mouth and pharynx, the 
atomizer may be used to advantage ; but the tube must be 
properly introduced into the nostrils. There are cases 
of nasal diphtheria, however, which are far more trouble- 
some to manage than the foregoing would seem to indicate. 
I have seen cases in which the nasal cavities, from the an- 
terior to the posterior nares, were filled and completely 
occluded by a dense solid membranous mass. I was then 
compelled to bore a passage with a silver probe, to gradu- 
ally introduce a larger-sized one, and then to apply the pure 
carbolic acid, in order to remove the densest and thickest 
masses, and finally was able to make injections ; even in 
such cases I have often had the gratification of being able 
to give a favorable prognosis. The dangerous secondary 
swellings of the glands will often subside after a steady 
employment of disinfectant injections for from twelve to 
twenty-four hours, but it must not be forgotten that these 
injections require to be made very frequently, either every 
hour or half-hour. We must not be drawn from our line of 
duty by the patient's desire for rest and sleep, but must 
continue the treatment uninterruptedly. It will be found 
that the children frequently do not object to this method 
of treatment ; I have even met with some who, after con- 
vincing themselves of the relief afforded thereby, asked 
for an injection. When we are about to bring each in- 
jection to a close, it is well to press together the nasal 
cavities for an instant with the fingers. By this proce- 
dure the fluid (unless doing so spontaneously) is forced 
backwards to the pharynx, and is swallowed or ejected 
through the mouth and thus washes the pharynx and 
mouth at the same time. Frequently, however, this latter 
object is obtained with every injection ; for, the palate 
being swelled, cedematous, and paretic, the fluid is not 



220 A TREATISE ON DIPHTHERIA. 

prevented from reaching the pharynx, even in the 
average case. In regard to the choice of a disinfect- 
ing agent, I have but a few words to say. I believe 
that no one of them has important qualifications above 
the others. I avoid those which stain, and produce 
firm coagula. For the latter reason I do not use the sub- 
sulphate and perchloride of iron ; for the former, the per- 
manganate of potassium. I employ, as a rule, carbolic 
acid in solution, of the strength above mentioned. Where 
there is but a slightly foetid odor, I have frequently em- 
ployed lime-water, or water, with glycerine, or a solution 
(i : ioo, i : 50) of chloride of sodium, or sod. bicarb., also 
sod. biborate. Disinfecting agents and antiseptics, whether 
carbolic acid, salicylic acid, or iron, are of no service when 
administered internally only, unless the seat and cause of 
the septic infection be attended to previously. I refer to 
what I have said above in relation to iron and salicylic 
acid. Under the local employment of antiseptics, as de- 
scribed, or by simply washing out with water, or salt 
water, most cases recover; without them, death will 
result. This much my experience has assured me of, that 
there is a certain number of cases which terminate fatally ; 
but it is likewise true that the mortality need not. be ex- 
cessively great. It is a great satisfaction to me learn from 
a recent paper of R. J. Nunn (The Indep. Pract, Sept., 
1880) that my method is appreciated and valued to its 
full extent. The author speaks very highly of the local 
treatment with iodine and boracic acid. I cannot grant 
that it is hard to carry out the exact and apparently bar- 
barous treatment necessary for a favorable result, for it 
is certainly more barbarous to sacrifice than to save life. 

It is a positive fact that when children suffering from 
nasal diphtheria, with its peculiarly septic character, are 
permitted to sleep much — and they are apt to be drowsy 
under the influence of the poison— they will certainly die. 
To allow them to sleep is to allow them to die. 

The first symptom of improvement is often a rapid 



TREATMENT. 221 

diminution of the glandular swelling. But not in all cases 
of nasal diphtheria these glandular swellings will be so 
prominent ; in fact, it would be expecting too much to 
suppose that all at once there should be a rule allowing 
of no exception. The exceptions are of twofold nature : 
ist. There is very little absorption through the lymphatic 
ducts, and very little, if any, glandular swelling in such 
cases where the very beginning of the disease is marked 
by slight hemorrhages, or by a discharge of bloody serum 
from the nostrils. In these cases, the blood-vessels are so 
superficial that they rupture and aid in macerating and 
sweeping off the membrane before absorption into the 
lymph circulation can take place. These cases are not 
always, however, mild in character. Open blood-vessels 
do not only discharge, they are also apt to absorb ; and thus 
it is that many of these cases, be the glandular swelling 
ever so slight, prove very serious, and thus also, that they 
can be saved by very frequent disinfection only. The 
second exception is formed by those cases in which nasal 
diphtheria, or any other, attacks a mucous membrane 
which has been the seat of chronic catarrh and intestinal 
cellulitis, with consecutive thickening, induration, and 
shrinking. In color, thickness, and consistency, a normal 
tonsil, pharynx, or Schneiderian membrane differs greatly 
from those which have undergone a hyperplastic tissue- 
change. In the latter condition, blood-vessels and lymph 
ducts are compressed and atrophied, and no longer a high 
road into the system. It is, therefore, rather hazardous 
on the part of as careful a practitioner as Dr. Ripley (Med. 
Rec, July 24th, 1880, p. 90) to declare it a folly to expect 
to cure the disease by any local application ; or of trying 
to prevent auto-infection in a system already charged with 
the poison. For as there are cases in which its feverless 
character and the local changes clearly mark a case as 
probably of merely local origin, local treatment, if it could 
or can be applied, is indicated in just these cases ; and 
secondly, the " system being charged with the poison" 



222 A TREATISE ON DIPHTHERIA. 

does not mean an unalterable condition ; for while elimin- 
ation is going on constantly, absorption of new poison is 
keeping pace with it more or less. Not even death is an 
unchangeable condition, much less a morbid process. Be- 
sides, Dr. Ripley says: " Even on the theory that these 
children die of septicaemia, and that the poison is absorbed 
from the nasal cavities, is syringing out these cavities 
several times an hour indicated ? Who thinks of washing 
out an infected uterus, or abscess of the pleural cavity, or 
other organ, with any such frequency ? " Certainly no- 
body, but nobody ever thinks of an equality of condition 
in nasal diphtheria on one hand, and a puerperal uterus or 
an abscess on the other. Even in the impossible case that 
all the membranes were washed away by a nasal injection, 
it is nothing new that the membranes will form again and 
again, and thus there is always, in addition to the former 
infection, a new one, and a necessity to meet it. If the 
doctor says: "If carried out as recommended, it must 
prove a most exhausting plan of treatment," I refer him 
to what he relies on, viz., clinical observation, and very 
much desire he should try and be satisfied. 

THE LARYNX. 

The severest form of diphtheria is that located in the 
larynx, "membranous croup." Its pathology has been 
discussed elsewhere. Its general treatment, whether the 
disease has originated primarily in the larynx or trachea, 
or been communicated from the pharynx, does not differ 
from that laid down for diphtheria in general. Naturally 
the larynx, with its principal symptom of stenosis (croup) of 
the organ, viz., the suffocatory phenomena, call for special 
treatment. This is represented by the administration of 
an emetic to fulfil the indication of removing mucus or 
partly detached membranes from the larynx. Such is their 
only indication in my experience. I never could satis- 
factorily explain the reason why Fordyce Barker's cases 
of membranous croup should all get well with no other 



TREATMENT. 



223 



treatment except repeated emetic doses of the yellow sul- 
phate of mercury (turpeth mineral). Somewhat like him, 
Lissdorf (Memor., 1876, p. 263) claims to have lost but five 
per cent of his two hundred croup cases treated with re- 
peated doses of sulphate of copper. Similar results are 
claimed by M. H. de Bey (Beitrag zur Casuistik, etc., 
1879), but he adds: "It is true the diagnosis, in the 
majority of cases, was made from the well-known sounds 
of respiration and cough only ; in some, however, by the 
expectoration of membranes." Thus, evidently, the 
majority of cases were not those of membranous croup, 
but of " pseudo-croup," or laryngeal catarrh. 

The selection of the emetic, when indicated, is of great 
importance. Antimonials ought to be avoided because of 
their depressing and purgative effect. Ipecac is but 
rarely effective. The sulphates of zinc, and particularly 
of copper, deserve preference. Turpeth mineral acts 
promptly and satisfactorily. When no emesis can be ob- 
tained, the prognosis is decidedly bad. 

The mechanical treatment of membranous croup by the 
introduction of tubes (" tubage ") into the diseased larynx 
has first been recommended by Loiseau, and afterwards 
by Bouchut. The latter author's enthusiastic praises of 
that method have contributed more than its deficient suc- 
cess to its speedy downfall. For not only did he claim 
complete comfort and relief from dyspnoea for the pro- 
cedure, but instant restoration of the voice. Of late, 
Schroetter, Weinlechner, and Monti have employed 
catheters to provide an artificial aperture and dilatation. 

In regard to tracheotomy, that last resort in croup, 
1 cannot refrain from stating that, in proportion to 
the increasing severity of the diphtheritic epidemics, 
the results of tracheotomy in my hands and in those 
of others have grown worse and worse. Of sixty-seven 
tracheotomies which I published twelve years ago, 
twenty per cent recovered ; about two hundred tracheo- 
tomies performed by me since that time, brought down 



224 A TREATISE ON DIPHTHERIA. 

the percentage of recoveries to such a low figure that only 
the utter impossibility of witnessing a child's dying from 
asphyxia has goaded me on to the performance of trache- 
otomy. I here add that I do not wish it to be inferred 
that I have changed my views concerning the indications 
for the operation of tracheotomy, as Boehme (p. 10) seems 
to believe. On the contrary. In spite of numerous ill 
successes, I hold to the principle, that where there is 
danger from suffocation through stenosis of the larynx, 
there is the indication for tracheotomy. Where there is 
no stenosis, I am glad not to operate. The results are 
not so bad, after all, when we remember that only such 
cases are operated upon which would be sure to die, if 
the operation were not performed. Even the number of 
children under two years saved by tracheotomy is increas- 
ing yearly. Kronlein reports 567 cases of diphtheria ob- 
served in the clinic of Berlin. Tracheotomy was per- 
formed in 504, with an average mortality of 70.8 per cent ; 
the rate decreasing from 83.7 in 1870 to 61.81 in 1876. In 
the first year of life, the rate of deaths after tracheotomy 
was 93.3 ; in the second, 85.7 ; in the third, 80 ; and so on 
to 67.3; 66.6; 56; 76.4; 52.1; 53.5; 42.8; 66.6; 60 (in the 
twelfth year). The youngest child was 7 months old when 
it recovered. Of 85 under two years, 11 recovered. 

The 400 cases of tracheotomy, reported by O. Wanscher 
as having been performed in Copenhagen from 1863 to 
1876, yield even more favorable results. The rate of re- 
coveries is as high as 42.1 per cent. He, too, finds the 
mortality increasing with the procrastination of the oper- 
ation. Even infants under two years of age recovered, 
provided the operation was performed at an early period. 

Of 50 cases of tracheotomy of Buchanan's (Brit. Med. 
Jour., April 10th, 1880), 17 were classed as croup, and 33 
as diphtheria, the latter including all those forms in which 
there was a distinct deposit of false white membrane on 
the tonsils, palate, or fauces. Of those 17 patients, 10 
died, 1 of whom immediately after the operation, the 



TREATMENT. 225 

others in from 3 hours to 4 days. Of the 33 there was a 
mortality of 21, 1 of whom also died immediately after the 
operation, the others in from 6 hours to 13 days. 

The indications, after the performance of the operation, 
in regard to the general process remain the same. There- 
fore, the general medicinal and dietetic treatment must 
be continued. Disinfection of the wound by zinc chloride, 
before the stitches are applied, is advisable. When the 
wound shows a diphtheritic appearance after twenty-four 
hours, sooner or later, or when the neighboring tissues 
swell, or when erysipelas shows itself, the stitches ought 
to be removed, and the wound treated with acid, carbolic, 
pur. and glycerine aa. While the disinfecting local treat- 
ment of the nose and pharynx is continued, a similar 
treatment is resorted to in regard to the trachea. I have 
atomized through the tube, in many cases, a two-per-cent 
solution of carbolic acid, every hour, every half-hour; in 
most cases, however, used a solution of carbolic acid in 
water (}4~S P er cent), or in lime-water, or lime-water 
with glycerine. This procedure has been kept up 
every quarter of an hour, every half-hour, every hour, for 
days in succession. The children are not annoyed by the 
proceeding and rarely get awake except from a severe at- 
tack of coughing. The atomizing is repeated very fre- 
quently, but a single compression of the balloon suffices 
for the purpose. For more direct and thorough appli- 
cations — the tube either being removed for the purpose, 
or mostly through it — I use a long pigeon's or hen's 
feather, carefully examined before using, dipped in a so- 
lution of carbolic acid (1) to aq. calc. and glycerine (aa 
5), or usually glycerine only (8-10). The amount of that 
liquid introduced into the trachea on that best of all in- 
struments for the purpose : flexible, uninjurious, and ef- 
fective, is sufficiently large, but not too large. A number 
of cases I have also exposed to a constant carbolic acid 
spray (2-3 per cent) ; a few I have treated with permanent 
turpentine inhalations as described above. All of them 
15 



226 A TREATISE ON DIPHTHERIA. 

were kept under the influence of steam. Thus surely Dr. 
Pauly is not correct when he attributes my acknowledged 
want of success with tracheotomy, during- the last ten 
years, to my neglect of inhalations after the operation, nor 
was his prophesy, that the results would be better in 
future. I must admit that they have continued to be but 
unfavorable, though, having tracheotomized these twenty 
years more frequently, perhaps, than any physician in the 
States, I have been as anxious as any one to use every 
means in my power to disinfect.* 

When, after the operation, the relief is next to none, 
particularly when the case takes a very rapid course, it is 
probably one of ascending croup which commenced in 
in the trachea. Mechanical relief by pushing down the 
hen's feather, or a bundle of them, and turning it about 
and twisting must be tried. It is a much better instru- 
ment than pincers of all sorts and shapes. But what 
relief will be accomplished is of but very short dur- 
ation. When fever will set in within a few hours, it 
means very much more frequently pneumonia than diph- 
theritic fever. It will soon be complicated by that dispro- 
portion between pulse and respiration so characteristic 
to inflammatory diseases. Then quinia in larger doses, 
0.25, or 0.5 (grs. iv.-viij.) every two, four, eight hours, at 
the same time doses of sodium salicylate 0.25-0.40 (grs. iv. 
-vi.) every hour or two hours until the temperature goes 
down, small doses of digitalis, where the heart requires it, 
must be given at once. Procrastination is dangerous, the 
patients want careful watching, most of them die within 
two days after the operation. 

The results of any treatment in membranous croup are 

* Dr. Al. Hadden assures me that liq. subsulphat. ferri applied to the 
treachea, after the operation, has saved some of his cases. With boric acid, 
muriatic acid, bromid. ammon., aq. chlorin., pot. hypermangan., sod. salicyl., 
sod. sulpho-carbol., zinc, sulph.-carbol, I have not, like Kronlein, experi- 
mented. Like him, I have used alum, borax, pepsin, lime-water, but have in 
most cases proceeded as above described. 



TREATMENT. 227 

01 so doubtful a character that any observation faithfully 
both made and reported may be of service. Bela Weiss 
relieved a boy of six years with undoubted croup by 
" massage," in the same manner in which he had previ- 
ously removed the urgent symptoms of pseudo-croup. 
The child sat on the lap of the mother, who held his head 
backwards, the doctor, sitting in front of the patient, placed 
a hand on either side of the neck, interlocking four fingers 
of either hand — well oiled — posteriorly, prayer fashion, 
and moved his thumbs slowly and gently in the be- 
ginning, more forcibly afterward, from the horizontal 
ramus of the lower jaw down to the clavicle, raised the 
thumbs, and repeated the same manoeuvre through five 
minutes and more. This operation was repeated a number 
of times in intervals of several hours, with favorable re- 
sults. Respiration became easier, cough looser, mem- 
branes were expectorated. The author adds that cold 
applications, warm inhalations, a short time also potassium 
chlorate were resorted to in the usual manner, and recom- 
mends his treatment, not as a panacea, but as successful 
in that case and worthy of further trials.* 

J. Szeparowicz (Centralb. f. Chir., No. 26, 1880) treated, 
in accordance with Schroetter's advice, a contraction of 
the larynx with bougies. A girl of four years had been 
tracheotomized for croup, eight months previously. The 
dilatation was persisted in for four weeks, with complete 
success. 

Whether the symptoms arise from a marked degree of 
cedematous infiltration of the tissues, or from fibrinous 
exudation or degeneration of epithelium, need not concern 
us as far as tracheotomy comes into question. In the first 
class of cases, the after-treatment is more successful, be- 
cause the trachea is more apt to be spared. Just as little 
need we consider whether, in individual cases, " the differ- 



* Casuistische Mittheilungen iiber die Anwendung der Massage bei Laryn- 
gitis catarrhalis und crouposa. Arch. f. Kinderheilkunde, 1880, p. 201. 



228 A TREATISE ON DIPHTHERIA. 

ehtial histological diagnosis has been made between diph- 
theria and croup." 

DIPHTHERITIC PARALYSES. 

The treatment of diphtheritic paralysis is simple enough 
in many cases; for sometimes nothing but patience and 
waiting are necessary. The limbs are usually restored to 
their normal condition, if the circumstances be in any way 
favorable. Anasmia and debility are invariable concom- 
itants, and the diet and medical treatment must be regu- 
lated accordingly. We must not forget, however, that 
overfeeding and a sameness of diet are not permitted, for 
not rarely the muscular coat of the stomach suffers with 
the rest of the muscular tissue, and the secretion of 
gastric juice is very deficient in ansemic individuals. 
While therefore, from a therapeutic stand-point, iron is 
indicated, we must not neglect to pay particular attention 
to nutrition and digestion, and to aid the latter with 
pepsin and moderate amounts of muriatic acid, well di- 
luted. Quinine and stimulants are appropriate wherever 
there is no contra-indication to their employment. The 
treatment of the paralysis itself, where it is not deemed 
judicious to wait, will naturally depend on the diagnosis 
of the condition in question. This alone can explain why 
various modes of treatment, the electric current among 
others, after being recommended by some authors, are 
branded by others. Where we have to deal with those rare 
changes in the brain and spinal cord, with apoplexy, " the 
utmost care is necessary " in order "not to make the con- 
dition still worse," and in such cases there would be a 
contra-indication to the use of the faradic current, but this 
would not hold true with regard to the use of the galvanic 
current in short sittings. Besides, central paralyses are 
by no means so frequent as peripherous ones. In most cases, 
there is not the slightest elevation of temperature during the 
course of the paralytic phenomena. I lay great stress upon 
this point, for I am aware that many cases of central con- 



TREATMENT. 229 

gestions and inflammatory processes at times exhibit but 
very insignificant elevations of temperature. But as the 
diagnosis will depend on a positive knowledge of whether 
there have been changes of temperature, I rely on the 
rectal temperature only, for many a myelitis runs its 
course with no greater elevation above the normal than 
one-half or one degree. In all cases in which the temper- 
ature is normal or subnormal, I do not hesitate for a 
moment to employ the faradic or the galvanic current, 
according to circumstances. In addition to the internal 
administration of iron, I advise by all means the employ- 
ment of nux vomica, in the form of strychnia. I cannot 
indorse Oertel's warning against the use of strychnia, on 
the ground that, as it acts centrally, it will positively give 
rise to an increased irritation of the morbid process in the 
spinal cord. The observations of a great many authori- 
ties, and my own which are rather extensive, cause me to 
look upon strychnia as the most reliable remedy in diph- 
theritic paralysis. Where there is no necessity for haste, 
we may give moderate doses, gradually increasing, in 
combination with iron ; where there is danger in delay, it 
is more judicious to have recourse to subcutaneous injec- 
tions, administered at regular intervals. Henoch has 
seen diphtheritic paralyses disappear in three weeks, 
under the use of hypodermic injections of strychnia. 
This, which has also been my experience on many occa- 
sions, corresponds with what Demme says (tenth report, 
1873) in connection with the treatment of infantile 
paralysis. His statements I have seen verified in the 
latter disease, in cerebral paralyses and in diphtheritic 
paralysis. It also agrees with the favorable results from 
subcutaneous injections of strychnia in the temples in 
amaurosis, which Nagel was the first to witness, and 
which since have been observed by others, and by myself 
in several cases. I especially advocate the use of injec- 
tions where there are urgent and dangerous paralytic 
manifestatious, as in case of danger depending on the 



230 A TREATISE ON DIPHTHERIA. 

paralysis of the muscles of deglutition and of respiration. 
Of course, where the former are affected, it is necessary to 
nourish the patient artificially, partly perhaps by nutrient 
enemata, but principally by means of the stomach-tube. In 
using the latter, it is unnecessary to introduce it into the 
stomach, as it only requires to be passed a few inches be- 
low the affected parts, when the oesophagus, far from 
manifesting the repugnance displayed by the pharynx, 
undertakes the further disposal of the food. In these 
cases, strychnia should be injected subcutaneously in the 
neck, once or twice daily. In a similar manner, it should 
be injected in the region of the chest, diaphragm, or neck, 
in paralysis of the respiratory muscles or of the glottis. In 
paralysis of the muscles of accommodation (in which 
Scheby-Buch claims to have seen the process cut short 
by the use of calabar bean, considered as insrt by Hassner) 
they may be given in the forehead or temples. 

Frictions dry and alcoholic, hot bathing, friction with 
hot water, kneading of the affected parts, will be found 
beneficial and pleasant. 

DIPHTHERITIC CONJUNCTIVITIS 

requires great attention and permits of no loss of time. 
Ice applications to the affected eye must be made con- 
stantly. Pieces of linen or lint kept on ice (better than in 
ice-water) of little more than the size of the eye, must be 
changed every minute or two, day and night. The dan- 
ger to the cornea is so imminent that constant watchful- 
ness is required. Boric acid in concentrated solution is, be- 
sides, dropped into the eye once every hour. The late Dr. 
H. Althof recommended and practised, where the rigidity 
of the eyelid was so great as to threaten rapid destruction 
of the cornea, a deep incision through the external angle to 
a distance of from one-half of an inch to an inch. Care 
must be taken that the well eye cannot get infected ; for 
that purpose it is best to cover it with lint and collodion, 
or lint, or cotton, and adhesive plaster. Local infections 



TREATMENT. 23 I 

of the kind are very frequent. But lately have I observed 
a local infection even of the tongue from a diphtheritic eye. 

CUTANEOUS DIPHTHERIA 

requires the destruction of the membrane or the infected 
surface by carbolic acid — either concentrated or somewhat 
diluted with glycerine — or the application of the actual 
cautery. After that, the use of ice, or iced cloths, or 
diluted carbolic acid are indicated. As soon as the sur- 
face is no longer diphtheritic, the local and general treat- 
ment is to be continued on general principles. 

SUMMARY. 

Every case should be treated on general principles, 
with symptomatics, roborants, stimulants, febrifuges, ex- 
ternally, internally, or hypodermically. 

The uncertainty of the termination, and the frequency 
of collapse or sepsis, prohibit procrastination. Waiting 
long means often waiting too long. 

Alcohol (p. 1 57) is a very important adjuvant and remedy. 
The dose must often be apparently large, from two to 
twelves ounces daily, according to circumstances. Deple- 
tion is absolutely contra-indicated. Debilitating compli- 
cations, such as diarrhea, must be stopped instantly. 

Mouth and neck must be kept in a healthy condition. 
Stomatitis, chronic pharyngitis, hypertrophy of the tonsils, 
glandular enlargements must be relieved or removed pre- 
ventively. Acute catarrh of mouth and pharynx requires 
the use of potassium or sodium chlorate (p. 159), in doses 
not exceeding a scruple daily for a child of a year, 1 J^-2 
drachms for an adult. The single doses must be small 
and very frequent, every hour, half, or quarter hour. 
Large doses are dangerous, result often in nephritis, and 
have proved fatal. 

The main indication in local diphtheria is local disinfec- 
tion (p. 169). To disinfect the blood effectively we have 
no means. Salicylic acid changes into a salicylate which 



232 A TREATISE ON DIPHTHERIA. 

is no longer a disinfectant. The amount of disinfectants 
required to destroy bacteria is so great that the living 
body could not endure them ; for instance, carbolic acid, 
quinine, and sulphur. But the discipline of the house, 
school, and social intercourse can be so modified as to pre- 
vent the spreading of an epidemic. The instructions for 
disinfectants published by the National Board of Health 
(p. 175) are as simple as they are effective. 

The inhalation of steam (p. 178) is very useful in catarrh 
of the respiratory organs, and also in inflammatory and 
diphtheritic affections. In fibrinous tracheo-bronchitis it 
has proved quite successful. But it may prove dangerous 
by excluding oxygen and overheating the room or tent. 
Drinking of large quantities of water (p. 181), with or 
without stimulants, also incites the action of the mucipar- 
ous glands and aids in macerating membranes. The in- 
ternal use of ice, and its local application to the affected 
parts, can be very useful. But the cases must be selected 
for each and any of the remedial agents and applications. 
The use of baths, and the cold or hot pack is controlled 
by general indications. The usefulness of lime-water (p. 
183) and lactic acid has been greatly overestimated. 
Glycerine is a valuable adjuvant both externally and in- 
ternally, but not more. Turpentine inhalations (p. 185) are 
deserving of further trials, though naturally they are more 
effective in purely inflammatory than in diphtheritic pro- 
cesses. Inhalations of ammonium chloride (p. 187) act 
favorably in catarrhal and inflammatory conditions, and 
deserve a trial for the purpose of aiding maceration of 
membranes. Mercurials (p. 188) are contra-indicated in 
the septic and gangrenous forms of diphtheria, but in 
those which assume more the purely inflammatory charac- 
ter with less constitutional debility and collapse, as in 
" sporadic croup," or in fibrinous tracheo-bronchitis, some 
reliable clinicians claim good results. 

Astringents, such as tannin and alum, do not work 
favorably (p. 190). 



TREATMENT. 233 

Chloride of iron (p. 191) is amongst the most reliable 
antiseptic and astringent agents. Small doses in long in- 
tervals are quite useless. Moderate doses frequently re- 
peated have a satisfactory general and local effect. A 
child of a year must take at least four grammes (a drachm) 
daily ; a child of three or four years, from eight to 
fifteen grammes. The same or a larger dose for an adult. 
The chloride is to be mixed with water and glycerine in 
various proportions, so that a dose is taken every hour, 
every half-hour, every ten minutes. Thus the local appli- 
cations to the throat become mostly superfluous. Potass- 
ium or sodium chlorate from two to four grammes ( 3 ss. 
-i.) daily may be added to advantage. 

Carbolic acid is useful both in local and internal ad- 
ministration. According to the end to be reached, it may 
be used either in concentrated form, or in a one-per-cent 
solution (p. 196). Internally, in doses of a few grains to 
half a drachm daily. 

Salicylic acid acts as a caustic when concentrated ; in 
moderate solutions it destroys fetor ; salicylates are anti- 
febriles only (p. 197). The antifebrile effects of quinine 
are not so favorable in infectious as in inflammatory 
fevers ; its antiseptic action is not satisfactory in practice 

( P . 198). 

Deliquescent caustics are dangerous. Injury of the 
healthy mucous membrane must be avoided. Mineral 
acids, and particularly carbolic acid, when their applica- 
tion can be limited to the desired locality, are preferable 
(p. 200). 

Bromine both internally and externally is warmly re- 
commended by Wm. H. Thompson (p. 201). 

Boric acid, in concentrated and milder solutions, has 
been recommended as a local application to membranous 
deposits generally, and to the diphtheritic conjunctiva in 
particular (p. 206). 

Sodium benzoate does not deserve the eulogies bestowed 
on it from theoretical reasoning (p. 207). 



234 A TREATISE ON DIPHTHERIA. 

Eucalyptus, sulphur, copaiba, and cubeb cannot be re- 
commended (p. 209). 

Membranes must not be torn off, and not removed un- 
less they are nearly detached. Caustics are contra-indi- 
cated except where their application can be limited to the 
diseased surface. No healthy part must be injured. 
Swelled lymph-glands require ice, iodine, iodoform, mer- 
cury, poultices, incision, carbolic acid, according to cir- 
cumstances (p. 216), and at all events frequent and careful 
disinfection of the mucous membrane from which their 
irritation originates. Diphtheria of the nose (p. 217) is 
apt to be fatal unless careful treatment is commenced at 
once. It consists of persistent disinfection of the nares 
and pharynx by means of injections. The tendency to 
sepsis forbids a long intermission of them. They must be 
continued day and night for one or several days, no mat- 
ter whether the glandular swelling is considerable or not. 

Laryngeal diphtheria (p. 222) proves fatal in almost 
every case, unless tracheotomy be performed. It is the 
less successful the more the epidemic or case bears a sep- 
tic character. Emetics, such as zinc, copper, or turpeth 
mineral, are useful for the removal of half detached mem- 
branes. 

Diphtheritic paralysis (p. 228) requires good and careful 
feeding, iron, strychnia, the faradic or galvanic currents, 
friction, hot bathing. Urgent cases indicate the hypoder- 
mic administration of strychnia. 

Diphtheritic conjunctivitis is benefited (p. 230) by ice 
and boric acid ; cutaneous diphtheria, by local cauterization 
and disinfection, besides general treatment. 



INDEX. 



Abscesses of lymphatic glands in diphtheria, 116. 

Absence of acinous glands to a certain extent prevents diphtheria of the vocal 

cords, 128. 
Adynamia in diphtheria, 51. 
Aetius, 1. 

Age when diphtheria occurs, 50. 

Air passages, anatomical appearances in the, table showing the, 126. 
Albuminous urine produced by chlorate of potassium, 166. 
Albuminuria in diphtheria, 51, 55, 90, 106, 136, 144. 

of scarlatina and diphtheria, diagnosis between, 90. 
Alum in the treatment of diphtheria, 190. 
America, first known case of diphtheria in, 3. 
Ammonium chloride in the treatment of diphtheria, 187. 
Anatomical appearances in diphtheria, 108 et seq. 

appearances of the epiglottis, 124. 

appearances of the mucous membrane of the mouth, 122. 

appearances of the mucous membrane of the nasal cavities, 123. 

appearances of the mucous membrane of the trachea and bronchi, 
125. 

appearances, table showing the, in the air passages, 126. 
Anaemia from diphtheritic paralysis, 228. 
Angina ulcusculosa, 4. 
Animals causing diphtheria in human beings, 65. 

with diphtheritic affections, 65. 
Antimonials in diphtheritic laryngitis, 223. 
Antiseptic nature of chloride of iron, 194. 
Antiseptics in diphtheria, 220. 
Aphonia in laryngeal diphtheria, 137. 

Applications, local, beneficial in nasal diphtheria, 220, 221. 
Aqua calcis in diphtheria, 21 1. 
Aretseus, 1. 

Artificial diphtheritic membrane, ill. 

Arytenoid cartilages, cicatrization of, a sequel of diphtheria, 73. 
Asclepiades, 1, 2. 
Aspergillus nigrescens, 66. 

Asthenic and suffocative forms of diphtheria, 2. 
Astringents in the treatment of diphtheria, 190. 



236 A TREATISE ON DIPHTHERIA. 

Ataxia, locomotor, in diphtheria, 101. 
Atomizer in treatment of diphtheria, 179. 
use of, in nasal diphtheria, 219. 
Autopsies in cases of diphtheritic paralyses, 103. 
Autopsy, first, in diphtheria, 3. 
Author's views as to origin of diphtheria, 54, 55. 

Bacteria, 170. 

destruction of, to prevent diphtheria, 174. 

experiments as to the methods of destroying, 174. 

in diphtheria, 49, 50, 111. 

not always found in diphtheria, 66. 

putrefaction without, 39. 

relation of, to diphtheria of the intestine, 117. 
Balano-posthitis, diphtheritic, 89. 
Ballonius, 2. 

Balsamica, the, in diphtheria, 209. 
Balsamics, the, nephritis following the use of, 210. 
Bard, 10, 165. 
Bastian, 23. 

Baths in diphtheria, 154. 
Benzoate of sodium in diphtheria, 170, 206. 
Bite causing diphtheria, 2. 
Bladder, diphtheria of the, 87. 
Bleeding in diphtheria, 157. 
Blood, the, in diphtheria, 92. 

Boric acid and iodine injections in nasal diphtheria, 220. 
acid in diphtheria, 206. 
acid in diphtheritic conjunctivitis, 230. 
Bougies used to remove contraction of larynx, 227. 
Brandy in diphtheria, 157. 
Bretonneau, 12, 13, 14, 16, 18, 165. 
Bromine in diphtheria, 200. 
Bronchi and trachea, mucous membrane of the, anatomical appearances of the, 

125. 
Bronchitis in children, 27. 
Broncho-pneumonia in diphtheria, 80. 

Caelius Aurelianus, 1. 

Calomel in diphtheria, 157, 189, 211. 

Calves affected by diphtheritic poison, 65. 

Carbolated sulphate of sodium in diphtheria, 211. 

Carbolic acid, amount required to disinfect, 174. 

acid as a disinfectant, 175, 195. 

acid in the destruction of bacteria, 174. 

acid in diphtheria, 195, 214. 

acid spray after tracheotomy, 225. 



INDEX. 237 

Catarrhal laryngitis, 138. 

Catarrh, chronic, after diphtheria, 104. 

chronic nasal, and so-called scrofula, 131. 

nasal, complicated with diphtheria, 72. 

nasal, followed by nasal diphtheria, 217. 
Catheterization in diphtheritic laryngitis, 223. 
Causes of diphtheria, 2, 25, 51, 52, 53, 61, 85. 

of frequency of diphtheria in children, 30. 
of pneumonia in diphtheria, 81. 
predisposing, of diphtheria, 32. 
Caustic action of salicylic acid, 197. 
Cauterization in diphtheria, 21 1. 

of diphtheritic membranes to be thoroughly done to be effective, 
200. 
Central origin of paralysis, 97. 
Chemical nature of diphtheritic poison, 50. 
Childhood, diphtheria a disease of, 49. 
Children, bronchitis in, 27. 

causes of frequency of diphtheria in, 30. 
infectious diseases in, 29. 
Chloral in diphtheria, 213. 
Chlorate of potassium, action of, upon the heart, 162. 

of potassium causing cyanosis, 163, 165. 

of potassium causing death, 163 et seq. 

of potassium causing nephritis, 163, 165. 

of potassium, convulsions produced by, 163. 

of potassium, danger of administration in large doses, 162. 

of potassium in the treatment of diphtheria, 160. 

of potassium producing albuminous urine, 166. 

of potassium and of sodium, prophylactics in diphtheria, 159. 
Chloride of ammonium in the treatment of diphtheria, 187. 

of iron, experiments with, 193. 

of iron in the treatment of diphtheria, 191, 211. 
Chlorine in diphtheria, 213. 
Chromic acid in diphtheria, 199. 

Cicatrization of arytenoid cartilages a sequel of diphtheria, 73. 
Ciliated epithelium less liable to be affected in diphtheria, 127. 
Circumcision-wounds, diphtheritic infection of, 88. 
Clothing of diphtheritic patients should be disinfected, 177. 
Cocco-bacteria dissolved and eliminated, 41. 

in the living blood not proven, 41. . 
Colden, Cadwallader, 7. 

Collapse and death in mild cases of diphtheria, 132. 
Communicability of diphtheria, 52. 
Complications, danger of, in diphtheria, 152. 
Congestion of the pharynx may be either traumatic or diphtheritic, 134. 



238 A TREATISE ON DIPHTHERIA. 

Conjunctivitis, diphtheritic, 17, 73, 143. 

diphtheritic, treatment of, 230. 
Constitutional nature of diphtheria, 52, 56. 
Contagiousness of diphtheria, 51, 57, 67. 
Contagium animatum, 36. 
Contraction of larynx relieved by bougies, 227. 
Convulsions a bad symptom in diphtheria, 70. 

produced by chlorate of potassium, 163. 
Copaiba in diphtheria, 209. 

Copperas solution to disinfect discharges from diphtheritic patients, 176. 
Corpses, manner of preparing, of diphtheritic patients after death, 177. 
Croup and diphtheria, symptoms compared, 139 et seq. 

and laryngeal diphtheria, identity or non-identity of, 112. 
ascending, 142. 
"massage " for relief of, 227. 
membranous, and diphtheritic laryngitis, 138. 
membranous, treatment of, 222. 
occurring when diphtheria is prevalent, 77, 78. 
prognosis in, 138. 
Croupous deposits in diphtheria, 70. 
diphtheria, 104. 

laryngitis and laryngeal diphtheria, 119. 

membrane formed by migration of white blood-corpuscles, no. 
Cubebs in diphtheria, 209. 
Curtis and Satterthwaite, 23, 43. 
Cutaneous diphtheria, treatment of, 231. 
Cyanosis an unfavorable sign in diphtheria, 153. 

resulting from an over-dose of chlorate of potassium, 163, 165. 
ushers in death in tracheal diphtheria, 143. 

Danforth, 3. 

Danger of allowing children affected with nasal diphtheria to sleep, 220. 

of complications in diphtheria, 152. 

of conveying diphtheritic poison during an epidemic, 158. 

of incisions for rigidity of the eyelid in diphtheritic conjunctivitis, 230. 
Dead bodies of diphtheritic patients to be kept moist, 173. 
Death caused by chlorate of potassium, 163 et seq. 
-rate in diphtheria, 157. 
sudden, in mild cases of diphtheria, 132. 
Debility from diphtheritic paralysis, 228. 
Deformity of penis caused by diphtheria, 90. 
Deglutition, difficulty of, caused by paralysis, 99. 
Deodorizers, definition of, 175. 
Deposits in diphtheria, 69. 
Destruction of the eye in diphtheria, 73, 105. 
Diagnosis between albuminuria of scarlatina and diphtheria, 90. 



INDEX. 

Diagnosis between enteritis and diphtheria, 84. 

between stomatitis and diphtheria, 134. 
of diphtheria, 134. 
of membranous laryngitis, 137. 
of myelitis in diphtheria, 229. 
Diagnostic feature in diphtheritic tracheo-bronchitis, 79. 
Diarrhoea, treatment of, in diphtheria, 158. 
Digestion interfered with by chlorate of potassium, 162. 
Digitalis after performance of tracheotomy, 226. 
Diphtheria a constitutional disease, 56. 

a disease of childhood, 49. 

after circumcision, 88. 

after urethrotomy and lithotomy, 88. 

age when it occurs, 50. 

albumen in urine in, 51, 55, 90, 136, 144. 

an adynamic disease, 51. 

anatomical appearances in, 108 et seq. 

and croup, symptoms compared, 139 et seq. 

and erysipelas, relations between, 86. 

and filth, 34. 

and milk, 63. 

and scarlatinal albuminuria, diagnosis between, 90. 

and stomatitis, diagnosis between, 134. 

antiseptics in, 220. 

apt to recur, 50. 

at different ages, 30. 

author's views as to origin of, 54, 55. 

bacteria in, 49, 50. 

broncho-pneumonia in, 80. 

causes of, 2, 25, 51, 52, 53, 61, 85. 

causes of frequency of, in children, 30. 

causes of pneumonia in, 81. 

causing deformity of penis, 90. 

changes of temperature in, 33. 

cicatrization of arytenoid cartilages a sequel of, 73. 

ciliated epithelium less liable to be affected in, 127. 

communicability of, 52. 

communicated by animals, 64, 65. 

communicated by kissing, 58. 

complicating various diseases, 72, 81, 82. 

considered by some a parasitic disease, 23- 

considered by some a self-limited disease, 156. 

constitutional symptoms in, 51. 

contagiousness of, 51, 67. 

convulsions and vomiting bad symptoms in, 70. 

croupous deposits in, 70. 



239 



240 A TREATISE ON DIPHTHERIA. 

Diphtheria, danger of complications in, 152. 

diagnosis between enteritis and, 84. 

diagnosis of, 134. 

diagnosis of myelitis in, 229. 

difference in invasion of, 54. 

disinfectants in, 220. 

division of remedies in, 178. 

duration of incubation of, 51, 59, 60. 

duration of prodromal stage of, 68. 

ecchymoses in, 91. 

emboli in, 115. 

endemic causes of, 62. 

epidemic nature of, 51, 61. 

epistaxis in, 145. 

etiology of, 27. 

excrements to be removed in, 173. 

fever not always a prominent symptom in, 135. 

fibrinous pneumonia in, 80. 

first autopsy in, 3. 

first known case in America, 3. 

first seen in respiratory passages, 53. 

forms of, 104. 

frequency of, 49. 

frequency of relapses in, 32. 

gangrene in, 71, 145. 

has a predilection for certain organs and localities, 120, 133. 

heart affections in, 91. 

histoiy of, I. 

identity of all forms of, 10. 

immunity from, 50. 

incubation of, in animals, 65. 

infectious nature of, 58. 

inflammatory affections of the lungs in, 80. 

influence of season on, 33. 

infrequent from third to seventh month, 31. 

in France, 10. 

in Holland, 10. 

in New England, 3, 4. 

in Sweden, 10. 

in Switzerland, 10. 

insidious nature of, 53. 

intestinal, 84. 

in the fowl, 66. 

isolation in, 158, 171. 

laryngeal, and croup, identity or non-identity of, 112. 

laryngeal, and croupous laryngitis, 119. 



INDEX. 241 

Diphtheria, laryngeal and tracheal, local in character, 128. 
laryngeal, in the adult, 27. 
leucocytes in, 113, 114. 
locomotor ataxia in, 101. 
lung affections in, 115. 
manifestations of, 69, 70. 
manner of infection in, 51. 
mechanical removal of membranes in, 214. 
micrococci as carriers of, 24. 
mild cases of, sudden collapse and death in, 132. 
mitral valve affected in, 91. 
mortality in, 150. 
nasal, 72. 

nasal, sleep dangerous in, 226. 
nasal, very fatal, 129, 133. 
not necessarily caused by polluted water, 62. 
nourishment, 162. 

often accompanied by pharyngitis, 53. 
of the vocal cords, danger of suffocation in, 129. 
of the vocal cords, general infection uncommon in, 128, 129. 
or muguet, 134. 
paralysis in, 52, 73, 96, 97. 
parasitic nature of, not proven, 49. 
pavement epithelium liable to be affected in, 127. 
pharyngeal membrane often first affected in, 53. 
predisposing causes of, 32. 
primary, of the trachea, 142. 
prognosis in, 149 et seq. 
prone to affect mucous membranes, 121. 
prophylaxis and prophylactics in, 58, 158, 159, 172. 
pseudo-leukaemia in, 92. 
sequelae of, 73. 

severity of, dependent upon the vascular and lymphatic systems, 129. 
severity of paralysis in, 97. 
sewers and, 34. 
sex in, 29. 

skin eruption in, 144. 

sometimes limited to certain localities, 121. 
strabismus in, 10. 

suffocative and asthenic forms of, 2. 
swelling of the glands in, 131, 133. 
symptoms of, 68. 
synonyms of, 1. 
temperature in, 55, 68. 
the blood in, 92. 

the soft palate and pharynx in, 69. 
16 



242 A TREATISE ON DIPHTHERIA. 

Diphtheria, thrombi in, 91. 

tonsils in, 30. 

treatment of, 154 et seq. 
Diphtheritic affections in animals, 65. 

fever, 91. 

laryngitis and membranous croup, 138. 

membrane, 70. 

membrane, artificial, ill. 

membrane, character of, determined by amount of elastic tissue, 
number of muciparous glands, etc., 122. 

membrane does not originate in epithelium according to some, 112. 

membranes, cauterization of, to be thoroughly done to be effective, 
200. 

membranes on the vocal cords not easily thrown off, 129. 

membranes to be rendered innocuous, 199. 

membranes, various methods of dissolving, 183, 184, 188, 189. 

patients, their corpses should be kept moist, 173. 

paralyses, 2, 96, 106, 145. 

paralyses, causes of, 98. 

paralyses do not run a certain course, 97. 

paralyses, electrical applications in, 103. 

paralyses, statistics of, 99. 

poison, chemical nature of, 50. 

poison, danger of conveyance of, during an epidemic, 158. 

poison impeded by the mucous glands, 127. 

poison, manner of entrance into system, 52. 

process affected by the character of the surface, 124. 

process, doctrines as to the, 109 et seq. 

process, statistics of the, 114. 

tracheo-bronchitis, 77. 
Discharges from diphtheritic patients to be received in vessels containing copperas 

solution, 176. 
Disinfectant properties of carbolic acid, 174, 195. 

properties of salicylic acid, 197. 
Disinfectants eighty years ago, 9. 
in diphtheria, 220. 
mode of using, 176. 
Disinfection of the clothing of diphtheritic patients, 177. 

of the wound caused by tracheotomy, 225. 

to be enforced by authorities in an epidemic of diphtheria, 172. 

to prevent diphtheria, 173. 
Douglass, 3. 

Duration of incubation of diphtheria, 59, 60. 
Drainage, bad, a cause of diphtheria, 61. 
Dyspnoea in laryngeal diphtheria without accompanying formation of membrane, 

137. 



INDEX. 



243 



Ecchymoses in diphtheria, 91. 

Elastic tissue, amount of, determines the character of the diphtheritic membrane 

in some cases, 122. 
Electrical applications in diphtheritic paralysis, 103. 
Emetics in diphtheritic laryngitis, 223. 
Emboli in diphtheria, 115. 
Endemic causes of diphtheria, 62. 
Endocarditis, diphtheritic, 1 1 5. 

Endogenous formation of pus globules in epithelium doubted, no. 
Enteric fever complicated with diphtheria, 81, 82. 
Enteritis, diagnosis between diphtheria and, 84. 
Entrance of infectious material into the system, mode of, 130. 
Epidemic influences causing diphtheria, 53. 

nature of diphtheria, 51, 61. 
Epiglottis, anatomical appearances of the, 124. 

diphtheria of the, 76. 
Epistaxis in diphtheria, 145. 
Epithelial cells, changes in, considered by some characteristic of diphtheria, 109. 

changes in membrane in diphtheria, 108. 
Epithelium, ciliated, less liable to be affected in diphtheria, 127. 

endogenous formation of pus globules in, doubted, no. 
pavement, most liable to be affected in diphtheria, 127. 
the, according to some, is not the source of origin of diphtheritic 
membrane, 112. 
Eruptions of the scalp, treatment of, in diphtheria, 158. 

on the skin in diphtheria, 144. 
Erysipelas and diphtheria, relations between, 86. 
Etiology of diphtheria, 27. 
Eustachian tubes, diphtheria of, 74. 
Excrements to be removed in diphtheria, 173. 
Exhaustion in diphtheria, 155. 
Experiments with chloride of iron, 193. 
Exposure during tracheotomy causing diphtheria, 59. 
Extremities, upper and lower, paralysis of the, 100. 
Eye, destruction of the, in diphtheria, 105. 

diphtheria of the, 73. 
Eyelids, rigidity of, in diphtheritic conjunctivitis, 230. 

Fever, diphtheritic, 91. 

enteric, complicated with diphtheria, 81, 82. 

high, obscures diagnosis, 135. 

not always a prominent symptom in diphtheria, 135. 

relative absence of, pathognomonic of diphtheritic laryngitis, 138. 
Fibrinous pneumonia in diphtheria, 80. 
Filth and diphtheria, 34, 50. 
First known case of diphtheria in America, 3. 



244 A TREATISE ON DIPHTHERIA. 

Fowl affected with diphtheria, 66. 
Frequency of diphtheria, 10, 49. 

of diphtheria and pharyngitis, 53. 

of diphtheria in children, causes of, 30. 

of diphtheritic conjunctivitis, 74. 

of relapses in diphtheria, 32. 
Frictions in diphtheritic paralyses, 230. 
Fumigation by means of roll sulphur, manner of, 176. 

Galen, 1. 

Gangrene in diphtheria, 71. 145. 

" Garget," differential diagnosis of, 64. 

Gargles in diphtheria, 212. 

of chloride of iron not useful in diphtheria, 192. 
Gas prevents diphtheria, 5S. 
Geddings, 16. 

Genito-urinary organs, diphtheria of the, 86. 

Glands, absence of acinous, prevents diphtheria of the vocal cords in many cases, 
12S. 

lymphatic, appearances of, in diphtheria, 116. 

mucous, impede the action of diphtheritic poison, 127. 

swelling of the, in diphtheria, 131, 133. 

treatment of swelling of lymphatic, 216. 
Glandular swelling, diminution of, a good sign, 220. 

swellings, not always marked in diphtheria, 104. 
Glycerin as a solvent of diphtheritic membranes, 183. 
Graefe, 17. 

Granular infiltration characteristic of diphtheria, 10S. 
Granulation tissue, changes in, in diphtheria, 108. 

Hallier, 23, 47. 

Heart, action of chlorate of potassium upon, 162. 

affections in diphtheria, 91, 114. 
Henle, 36. 

History of diphtheria, 1. 

Hodgkin's disease occurring in diphtheria, 92. 
Holland, diphtheria in, 10. 
Home, 10. 
Hiiter, 109. 

Human beings inoculated with diphtheria by animals, 65. 
Hydrargyrum in the treatment of diphtheria, 183. 
Hypodermic injections of mercury in diphtheria, 190. 

Ice in diphtheria, 182, 230. 

Identity of all forms of diphtheria, 10. 

or non-identity of laryngeal diphtheria and croup, 112. 



INDEX. 245 

Immunity from diphtheria, 50. 

Incisions, danger of, for relief of rigidity of eyelid in diphtheritic conjunctivitis, 

230. 
Incubation of diphtheria, duration of, 51, 59, 60, 67. 

of diphtheria in animals, 65. 
Infection, general, a cause of diphtheria, 61. 

general, in diphtheria of the vocal cords uncommon, 129. 
of diphtheria, manner of, 51, 58. 
Infectious diseases in children, 29. 

material, mode of entrance of into the system, 130. 
nature of diphtheria, 58. 
Infiltration, granular, characteristic of diphtheria, 108. 
Inflammatory affections of the lungs in diphtheria, 80. 
Influenza complicated with diphtheria, 72. 
Inhalations in diphtheria, 212. 

of steam in diphtheria, 178, 181. 

of turpentine in the treatment of diphtheria, 185, 209. 
Injections in nasal diphtheria sometimes fatal, 218. 
of strychnia in diphtheritic paralysis, 229. 
Inoculability of diphtheria, 51. 
Insidious nature of diphtheria, 53. 
Insufflation of sulphur in diphtheria, 209. 
Intestinal canal, appearances of, in diphtheria, 116. 
Intestine, diphtheria of the, 84, 105. 
Invasion of diphtheria, difference in, 54. 
Iodine and boracic acid injections in nasal diphtheria, 220. 

ointments for swelling of the glands, 216. 
Ipecac in diphtheritic laryngitis, 223. 
Iron as a nervous stimulant, 195. 

increases the power of oxydation, 195. 
in the treatment of diphtheria, 176, 191, 193, 194, 211. 
Isambert, 18. 
Isolation in diphtheria, 158, 171. 

Josselyn, 3. 
J urine, 12. 

Kidneys, appearances of, in diphtheria, 116. 

diphtheria of the, 90. 

micrococci in the, 46. 
Kiss, a, communicating diphtheria, 58. 
Klebs, 23, 48. 

Lactic acid as a solvent of diphtheritic membranes, 183, 184. 
Laryngeal diphtheria, 136. 

diphtheria in the adult, 27. 

diphtheria, local in character, 128. 



246 A TREATISE ON DIPHTHERIA. 

Laryngeal diphtheria more frequent in boys, 50. 
Laryngitis, catarrhal, 138. 

diphtheritic, and membranous croup, 138. 

diphtheritic, treatment of, 222. 

membranous, diagnosis of, 137. 
Laryngoscopic examination in diphtheria, 136. 
Larynx, contraction of, relieved by bougies, 227. 

membranous deposits in, 138. 
Le Cat, 9. 
Letzerich, 48, 82. 

Leukocytes in diphtheria, 113, 114. 
Leukocythsemia in diphtheria, 92. 
Lime-water in diphtheria, 183, 211. 
Lithotomy causing diphtheria, 88. 
Liver, appearances of, in diphtheria, 116. 
Local applications beneficial in nasal diphtheria, 220, 221. 

origin of diphtheria, 52, 53. 
Locomotor ataxia in diphtheria, 101. 
Lugol's solution in diphtheria, 211. 
Lung affections in diphtheria, 80, 115. 
Lungs and trachea, mycosis of the, 65. 
Lymphadenitis generally severe in nasal diphtheria, 136. 

gives rise to sudden elevation in temperature, 135. 
not necessary to diagnose a case of diphtheria, 136. 
Lymphatic and vascular systems, severity of diphtheria dependent upon the, 129. 

glands, appearances of, in diphtheria, 116. 

glands, treatment of swelling of, 216. 
Lymphatics, effect of chloride of iron on the, 193. 

Maingault, 17. 

Manifestations of diphtheria, 69, 70. 
" Massage " for relief of croup, 226. 
Membrane, artificial diphtheritic, in. 
diphtheritic, 70. 

diphtheritic, according to some authorities does not originate in epi- 
thelium, 112. 
formation of, in diphtheria sometimes prevented by chlorate of 

potassium and sodium, 160. 
the, a characteristic sign in diphtheria, 108, 134. 
Membranes in intestinal diphtheria, 85. 

mechanical removal of, in diphtheria, 214. 
mucous, prone to be affected by diphtheria, 121. 
Membranous croup or diphtheritic laryngitis, 138. 
croup, treatment of, 222. 
deposits in larynx, 138. 
laryngitis, diagnosis of, 137. 



INDEX. 247 

Mercado, 2. 

Mercury given hypodermically in diphtheria, igo. 

given to liquefy diphtheritic membranes, 188, 189. 
in the treatment of diphtheria, 187. 
not a specific in diphtheria, 188. 
oleate of, in diphtheria, 190. 
sulphate of, in diphtheritic laryngitis, 223. 

to be given in small doses frequently to produce effect in diphtheria, 189. 
Micrococci, 194. 

as carriers of diphtheria, 24. 

disappear as erysipelatous process progresses, 40. 
excite no reaction, 25. 
in the kidneys, 46. 
Micro-organisms and septic poisons, no etiological connection between, 38. 
Middleton, 11. 

Milk a cause of diphtheria, 63. 
Mitral valve affected in diphtheria, 91. 
Mortality in diphtheria, 150. 
Mouth, diphtheria of the, 81, 105. 

mucous membrane of, anatomical appearances of, in diphtheria, 122. 
Muciparous glands, determining the character of diphtheritic membrane in cer- 
tain cases, 122. 
Muco-salivary diphtheritis caused by extirpation of the tongue, 85. 
Mucous glands impede the action of diphtheritic poison, 127. 

membrane of the mouth, anatomical appearances of, 122. 
membrane of the nasal passages, anatomical appearances of, 123. 
membrane of the trachea and bronchi, anatomical appearances of the, 

125. 
membranes prone to be affected by diphtheria, 121. 
Muguet or diphtheria, 134. 
Mycosis of the trachea and lungs, 65. 
Myelitis, diagnosis of, in diphtheria, 229. 
Mykosis oesophagi, 82. 

Nasal catarrh complicated with diphtheria, 72. 

catarrh, treatment of, during epidemics of diphtheria, 158. 

cavities affected in diphtheria, 71. 

cavities, mucous membrane of, anatomical appearances of, 123. 

diphtheria, 72. 

diphtheria following nasal catarrh, 217. 

diphtheria, lymphadenitis generally severe in, 136. 

diphtheria, sleep dangerous in, 220. 

diphtheria, treatment of, 217. 

diphtheria, very fatal, 129, 133. 
Necrotic diphtheria, 104. 
Nephritis following the use of the balsamics, 210. 



248 A TREATISE ON DIPHTHERIA. 

Nephritis resulting from an overdose of chlorate of potassium, 163, 165. 
Nervous system, affections of, in diphtheria, 93, 106. 

tissue, anomalies of nutrition of the, causing diphtheritic paralysis, 98 
Neurin as a solvent of diphtheritic membranes, 184. 
New England, diphtheria in, 3, 4. 

Nitrate of silver in the treatment of diphtheria, 190, 199. 
Nostrils of attendants on diphtheritic patients to be filled with cotton, 173. 
Nourishment in diphtheria, 154. 162. 

Nurses of diphtheritic patients to wear cotton in their nostrils, 173. 
Nutrition, anomalies of, of nervous tissue causing diphtheritic paralysis, 98. 

CEdema glottidis detected by palpation, 137. 

glottidis, general, uncommon in diphtheria, 137. 

glottidis in diphtheria, 76, 105. 
Oertel, 37, 38, 78, 155, 190, 229. 
Oesophagus, diphtheria of the, 82. 
Ogden, Jacob, 9. 

Oleum eucalypti e foliis in diphtheria, 209. 
Origin, local, of diphtheria, 52, 53. 

of diphtheria, author's views of the, 54, 55. 

of diphtheritic paralysis, 96. 
Otitis in diphtheria, 74. 
Oxydation increased by iron, 195. 
Ozone in diphtheria, 205. 

Palate, soft, in diphtheria, 69. 

Panum, 38, 46. 

Parasitic nature of diphtheria not proven, 23, 49. 

Paralyses, diphtheritic, treatment of, 228. 

peripheral, more frequent than central, 228. 
Paralysis, diphtheritic, 2, 52, 96, 142. 

diphtheritic, statistics of, 99. 

of central origin, 97. 

of the lower and upper extremities, 100. 

of the pneumogastric nerve in diphtheria, 96. 

of the sense of taste in diphtheria, 97. 

of the vocal cords, 138. 

severity of, in diphtheria, 97. 
Paresis of the thyro-arytenoid muscles a sequel of diphtheria, 73. 
Pathological appearances caused by diphtheritic endocarditis, 115. 
Pavement epithelium altered in diphtheria, 108. 

epithelium most liable to be affected in diphtheria, 127. 
Penis, deformity of, caused by diphtheria, 90. 
Pepsin as a solvent of diphtheritic membranes, 184. 
Perforation and destruction of the eye in diphtheria, 74. 
Peripheral more frequent than central paralyses, 228. 



INDEX. 



249 



Pharyngeal congestion may be either traumatic or diphtheritic, 134. 

membrane often first affected in diphtheria, 53. 
Pharyngitis and diphtheria, 53. 

occurring during diphtheria epidemics, 159. 
Pharynx in diphtheria, 68. 

often not affected in diphtheritic tracheo-bronchitis, 79. 
Placental diphtheria, 88. 

Phlegmon, incision of, resulting in diphtheria, 52. 
Pneumogastric nerve, paralysis of the, in diphtheria, 96. 
Pneumonia, causes of, in diphtheria, 81. 
diphtheritic, 143. 
fibrinous, in diphtheria, 80. 
Polluted water not necessarily a cause of diphtheria, 62. 
Potassa in diphtheria, 199. 
Potassium chlorate a prophylactic in diphtheria, 159. 

chlorate, effects of, in diphtheria, 160 et seq. 
Powers' investigation as to communicability of diphtheria by means of milk, 64. 
Predisposing causes of diphtheria, 32, 50, 58. 
Premises, the, should be disinfected with copperas solution, 177. 
Prevention of diphtheria, 158, 173. 
Primary diphtheria of the trachea, 142. 
Prodromal stage, duration of, of diphtheria, 68. 
Prognosis in croup, 138. 

in diphtheria, 149. 
Prophylactic agents in diphtheria, 58, 159. 
Pseudo-croup, 138. 

Pus globules, endogenous formation of, in epithelium doubted, no. 
Putrefaction without bacteria, 39. 

Quinia after the performance of tracheotomy, 226. 
in diphtheria, 154, 171, 198, 213, 228. 

Recurrence of diphtheria, 50. 

Relapses frequent in diphtheria, 32. 

Relations between erysipelas and diphtheria, 86. 

Removal, mechanical, of membranes in diphtheria, 214. 

Remedies in diphtheria, division of, 178. 

Respiratory muscles, paralysis of the, most dangerous, 101. 

organs affected in diphtheria, 75. 

passages, diphtheria first seen in the, 53. 
Rhinoscopic examination in diphtheria, 136. 
Rigidity of the eyelid in diphtheritic conjunctivitis, 230. 
Rokitansky, 81. 

Salicylate of sodium in diphtheria, 197, 211. 
Salicylic acid as a caustic, 197. 



250 A TREATISE ON DIPHTHERIA. 

Salicylic acid, disinfectant properties of, 197. 

acid in diphtheria, 170, 196. 
Satterthwaite and Curtis, 23, 43. 

Scarlatinal and diphtheritic albuminuria, diagnosis between, 90. 
Schools, necessity of closing them in diphtheria epidemics, 172. 
Sclerotic, destruction of, in diphtheria, 105. 
Scrofula, so-called and chronic nasal catarrh, 131. 
Season, influence of, on diphtheria, 33. 
Self-limitation of diphtheria, 156. 
Sensitive paralyses, 101 . 
Sequela? of diphtheria, 73. 
Severity of diphtheria dependent upon the vascular and lymphatic systems, 129. 

of paralysis in diphtheria, 97. 
Sewers and diphtheria, 34. 
Sex in diphtheria, 29. 
Silver nitrate in diphtheria, 199. 
Skin, diphtheria of the, 2, 86* 

diphtheritic poison introduced by the, 52. 
eruption in diphtheria, 144. 
Sleep dangerous in nasal diphtheria, 220. 
Sodii sulphatis carbolatoe in diphtheria, 211. 
Sodium benzoate in diphtheria, 170, 206. 

chlorate a prophylactic in diphtheria, 159, 160. 
salicylate of, in diphtheria, 154, 197, 211. 
Source of diphtheria, 50. 
Spleen, appearances of, in diphtheria, 116. 
Statistics of diphtheritic paralysis, 99. 

of the diphtheritic process, 114. 
of tracheotomy in diphtheritic laryngitis, 224. 
Steam, inhalations of, in diphtheria, 178, 181. 
Stimulants in diphtheria, 156. 
Stomach, diphtheria of the, 82. 
Stomatitis and diphtheria, diagnosis between, 134. 

follicularis not to be confounded with diphtheria, 134. 
occurring during diphtheria epidemics, 159. 
Strabismus in diphtheria, 10. 
Strychnia in diphtheritic paralyses, 229. 
Suffocation, danger of, in diphtheria of vocal cords, 129. 
Suffocative and asthenic forms of diphtheria, 2. 
Sulphurous acid in the destruction of bacteria, 174. 
Sulphur, roll, for fumigation, 176. 

insufflation of, in diphtheria, 209. 
Summary of anatomical appearances in diphtheria, 132. 
of diagnosis of diphtheria, 147. 
of etiology of diphtheria, 49. 
of history of diphtheria, 25. 



INDEX. 251 

Summary of manner of infection in diphtheria, 56. 

of symptoms of diphtheria, 104. 

of treatment of diphtheria, 231. 
Suppuration rare when glands swell in diphtheria, 217. 
Sweden, diphtheria in, 10. 
Swelling of the glands in diphtheria, 131, 133. 

of the glands in diphtheria, treatment of, 216. 
Switzerland, diphtheria in, 10. 
Symptoms of croup and diphtheria compared, 139 et seq . 

of diphtheria, 51, 68. 

of laryngeal diphtheria, 77. 
Synonyms of diphtheria, 1. 

Table showing the anatomical appearances in the air passages in diphtheria, 126. 

Tannin in the treatment of diphtheria, 190, 211. 

Taste, sense of, paralysis of, in diphtheria, 97. 

Temperature in diphtheria, 33, 55, 68. 

Thompson, W. H., on the effects of bromine in diphtheria, 200 et seq. 

Throat distemper, 5,7. 

the, in diphtheria, 70. 
Thrombi in diphtheria, 91. 
Tissues acting differently after inoculation, 42. 
Tommasi, 109. 

Tongue, extirpation of the, a cause of muco-salivary diphtheritis, 85. 
Tonics in diphtheria, 155. 
Tonsils in diphtheria, 30, 215. 

Trachea and bronchi, mucous membrane of the, anatomical appearances of the, 
125. 
and lungs, mycosis of the, 65. 
primary diphtheria of the, 142. 
Tracheal diphtheria, local in character, 128. 
Tracheotomy, 210. 

carbolic acid spray after, 225. 

causing diphtheria, 85. 

disinfection of wounds caused by, 225. 

exposure during, causing diphtheria, 59. 

in diphtheria, 150, 151, 215. 

in diphtheritic laryngitis, 223. 

in diphtheritic tracheo-bronchitis, 79. 

statistics of, in diphtheritic laryngitis, 224. 

treatment after its performance, 226. 

twice in the same subject, 27. 
Transmission of diphtheria by means of milk, 64. 
Treatment of diphtheria, 154 et seq. 

of diphtheritic laryngitis, 222. 
of diphtheritic paralyses, 228. 



252 A TREATISE ON DIPHTHERIA. 

Treatment of membranous croup, 222. 

of swelling of lymphatic glands, 216. 
Trousseau, 15, 17. 

Turpentine in the treatment of diphtheria, 185, 209. 
Turpeth mineral in diphtheritic laryngitis, 223. 
Typhoid fever complicated with diphtheria, 81, 82. 

Urethrotomy causing diphtheria, 88. 

Urine, albumen in the, in diphtheria, 90, 144. 

albuminous, produced by chlorate of potassium, 166. 

Vaginal diphtheria, 87, 143. 

Varieties of diphtheritic paralysis, 146. 

Vascular and lymphatic systems, severity of diphtheria dependent upon, 129. 

Virchow, 17, 21, 117, 118. 

Vocal cords, diphtheria of the, danger of suffocation in, 129. 

cords, diphtheria of the, general infection uncommon in, 129. 

cords, diphtheritic membranes on the, not easily thrown off, 129. 

cords, paralysis of, 138. 

cords resting places for diphtheritic poison, 133. 
Vomiting a bad symptom in diphtheria, 70. 

Vulvitis diphtheritica, 87. 

Wade, 20. 

Water in the treatment of diphtheria, 181 et seq. 

polluted, not necessarily a cause of diphtheria, 62. 
Wounds, diphtheria, of, 2, 85, 143. 

disinfection of, after tracheotomy, 225. 

Zinc sulphate as a disinfectant, 176. 



